New York Heart Association class associated with imaging is a prognostic mortality risk predictor in interstitial lung diseases

OBJECTIVE

Mortality risk factors as forced vital capacity, diffuse lung capacity for carbon monoxide, and 6-minutes' walk test were studied in clinical trials monitoring patients affected by interstitial lung diseases (ILD). However, these parameters showed scarce accuracy. Our aim was to identify New York Heart Association (NHYA) class, in association with high resolution computed tomography (HRCT) and somatostatin receptor scintigraphy (Octreoscan), as a prognostic mortality risk factor in ILD patients.

PATIENTS AND METHODS

Study population comprised 128 ILD patients (78 Males and 50 Females). Histological diagnosis was usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP) and granulomatous lung disease in 59, 19 and 50 patients, respectively. Patients were monitored by NYHA class, HRCT and Octreoscan at baseline and every 3 years up to a 10-year follow up. Overall survival was calculated from the date of diagnosis until death or last follow-up update. Statistical analysis was performed using Kaplan-Meier, log-rank test (LRT), multivariate analysis with Cox proportional hazard regression model, and log-likelihood ratio test.

RESULTS

Overall median survival was 89.3 months (7.4 years) with the poorer survival rate observed in UIP patients. NYHA class came out as a reliable prognostic mortality risk factor in each group of patients and prognosis was progressively worse with NYHA class increase (LRT p<0.001). A strong correlation was found between NYHA class and age, CT-score, and Octreoscan in UIP patients (p<0.001).

CONCLUSIONS

The determination of NYHA class can therefore be recommended as an additional prognostic mortality risk factor in ILD patients.

Role of Liver Transplantation in Bilio-Vascular Liver Injury After Cholecystectomy

BACKGROUND

The aim of this study was to report 2 cases of liver transplantation (LT) for iatrogenic bile-vascular injury (BVI) sustained during cholecystectomy and to review the literature for LT after cholecystectomy.

METHODS

Between March 2001 and July 2013, within our institution, 12 patients were treated after cholecystectomy, 3 of 12 received LT, 1 for acute de-compensation in a cirrhotic patient and 2 after iatrogenic lesions.

RESULTS

The majority of iatrogenic injury occurred during video-laparocholecystectomy (63,6%; 7/11). Three patients of 12 (25%) received LT: the first patient developed acute de-compensation in chronic and after liver failure. The second patient developed recurrent cholangitis and secondary biliary cirrhosis. The third patient had undergone emergency hepatectomy because of bleeding and subsequent total hepatectomy with porto-caval shunt. Five of 12 (42%) patients were treated with bilio-digestive anastomosis: 1 patient with direct repair on T-tube; 2 patients (17%) with arterial vascular lesion requiring surgical treatment; and 1 patient treated with medical therapy. No deaths occurred. The post-operative morbidity included 1 re-intervention, 3 recurrent cholangitis, 1 anastomotic biliary stricture, 1 anastomotic bile leak, and cholestasis in 3 patients. The overall hospital stays were higher after LT. Median follow-up was 8.25 years (range, 2-14).

CONCLUSIONS

The management of iatrogenic injury during cholecystectomy depends on the time of recognition, extent of injury, experience of the surgeon, and the patient's general condition. If safe repair is possible, BVI should be treated promptly, otherwise all patients should be treated in an experienced center.

Torque Teno Virus--cause of viral liver disease following liver transplantation: a case report

Torque Teno Virus (TTV), a nonenveloped human virus of the Circoviridae family, is hepatotropic, causing liver damage, cirrhosis, and, rarely, fulminant hepatitis. It prevails in 10% to 75% of blood donors due to environmental differences, independent of chronic hepatitis B virus (HBV)/HCV hepatitis, cryptogenic cirrhosis, alcoholic cirrhosis, and in fulminant hepatitis non-A-G. Reports about the efficacy of clinical alpha interferon are rare. In July 2007, a 65-year-old man who was serologically negative for A-E viruses presented with acute liver failure due to a ruptured hepatic artery aneurysm and underwent orthotopic liver transplantation (OLT). Immunosuppression was based on cyclosporine and steroids. At postoperative day 20, there was persistent hypertransaminasemia with otherwise normal liver function. A percutaneous hepatic biopsy documented pattern suggestive of a viral etiology. Multiple tests for hepatotropic viruses in the donor and the recipient from the pre- and post-OLT periods remained negative. Only the TTV qualitative test, assessed by polymerase chain reaction (PCR) on patient sera, was positive. Immunosuppressive therapy was not changed; no antiviral therapy was undertaken. At 6 months posttransplantation, transaminase levels spontaneously normalized and the clinical situation was unchanged. No complications were observed; the patient is in good clinical condition. No graft rejection was observed. In histologically proven non-A-E viral hepatitis, it is important to consider TTV as an incidental pathogenic agent. It may be useful to extend virological tests to TTV among transplant recipients and donors and to gain further knowledge about this virus.

Full-right-full-left split liver transplantation: the retrospective analysis of an early multicenter experience including graft sharing

Full-right-full-left split liver transplantation divides a donor liver into two grafts to be transplanted in adult-size patients. Major technical and organizational difficulties have limited its application to few single center series. We retrospectively analyzed the long-term results of the first multicenter series of this procedure with graft sharing. Between November 1998 and January 2005, 43 transplants were performed by five centers from 23 full-right-full-left in situ split liver procedures; 65% of the grafts were shared. A total of 31 (72%) patients had complications above grade II; 3 (6.9%) were retransplanted. Hospital mortality was 23% with sepsis as the main cause. Six patients died in the long term, two of them for a road accident. A total of 27 patients are alive after a median follow-up of 3200 days (2035-4256). Actuarial survival at 1 and 10 years were 72.1%, 62.6% and 65.1%, 57.9%, respectively for patients and grafts. These figures are similar to those reported for adult living donor liver transplantation by the European Registry over a similar period. Multicenter collaboration in sharing of these grafts is feasible and can help facing the organizational limits, thus increasing diffusion of full-right-full-left split liver transplantation.

Full-right-full-left split liver transplantation: the retrospective analysis of an early multicenter experience including graft sharing

Full-right-full-left split liver transplantation divides a donor liver into two grafts to be transplanted in adult-size patients. Major technical and organizational difficulties have limited its application to few single center series. We retrospectively analyzed the long-term results of the first multicenter series of this procedure with graft sharing. Between November 1998 and January 2005, 43 transplants were performed by five centers from 23 full-right-full-left in situ split liver procedures; 65% of the grafts were shared. A total of 31 (72%) patients had complications above grade II; 3 (6.9%) were retransplanted. Hospital mortality was 23% with sepsis as the main cause. Six patients died in the long term, two of them for a road accident. A total of 27 patients are alive after a median follow-up of 3200 days (2035-4256). Actuarial survival at 1 and 10 years were 72.1%, 62.6% and 65.1%, 57.9%, respectively for patients and grafts. These figures are similar to those reported for adult living donor liver transplantation by the European Registry over a similar period. Multicenter collaboration in sharing of these grafts is feasible and can help facing the organizational limits, thus increasing diffusion of full-right-full-left split liver transplantation.

Predictors of survival in idiopathic interstitial pneumonia

AIM

To evaluate the ability of newly identified clinical factors to predict prognosis and survival in idiopathic pulmonary fibrosis (IPF) and non-specific interstitial pneumonia (NSIP).

METHODS

Seventy-eight patients referred to the University of Genoa and the Regional Hospital of Aosta between January 1995 and December 2006 were evaluated prospectively. Fifty-nine patients were diagnosed with IPF and 19 with NSIP on the basis of surgical lung biopsy specimens. Gender, age at diagnosis, smoking, New York Heart Association class (NYHA), systolic pulmonary artery pressure (sPAP), Octreoscan uptake index (UI), and therapy were the chosen variables. Primary end-point was survival.

RESULTS

With the exception of gender and smoking history, all baseline patient characteristics correlated significantly with the diagnosis (IPF vs. NSIP). Median survival for the entire study group was 52.7 months. Univariate analysis showed poorer survival for the IPF group versus the NSIP group, and survival was significantly lower for older patients (p < 0.001). Multivariate analysis confirmed the negative prognostic effect of age (p < 0.001) on survival with a risk of death for older patients ( > OR =66 years old) being more than 4 times higher than that for younger patients (<58 yr.). NYHA class and pulmonary artery pressure were also significant predictors of survival, and all patients with a sPAP < OR = 35-mm Hg were alive at the end of the follow-up period. There was a good correlation between Octreoscan uptake index and the diagnosis.

CONCLUSION

Diagnosis (IPF vs. NSIP), NYHA class, sPAP, and especially age appear to represent important prognostic indicators in the two most prevalent forms of idiopathic pulmonary fibrosis (IPF and NSIP). Lower Octreoscan uptake values were found in all patients with IPF, suggesting that this test may have a role as a new predictor of survival for differentiating IPF from NSIP.

Preliminary results of liver transplantation for hepatocellular carcinoma among allocation organ policy strategies, neoadjuvant treatments, and intention-to-treat analysis

We retrospectively evaluated the impact of our strategy for patients with hepatocellular carcinoma (HCC) according to an intention-to-treat analysis and drop-out probability. We evaluated only patients within the Milan criteria. We analyzed the outcomes of neoadjuvant strategies for HCC, organ allocation policy, and systematic application of strategies to increase the deceased donor pool as the current tendency to expand transplantability criteria for those patients. Kaplan-Meier survival probability rates at 1, 3, and 5 years according to an intention-to-treat analysis were 87.02%, 74.53%, and 65.93% for transplanted patients (n=108), and 50%, 14.29%, and 14.29% for the excluded or waiting list group (n=13), respectively (P< .0001). Drop-out risk at 3, 6, and 12 months was 2.40%, 8.59%, and 16.54%, respectively. During the same period, the mortality probability rates at 3, 6, and 12 months among patients without HCC awaiting orthotopic liver transplantation (OLT) were 3.60%, 9.50%, and 18.34%, respectively. Drop-out rate was lower among patients treated before OLT (P< .0001). On the basis of the neoadjuvant treatment results to reduce drop-out risk, we suggest avoiding the high priority for the HCC cohort, particularly within the first 6 months from entrance on the waiting list, because this approach can reduce the chances of patients with end-stage liver disease (ESLD) alone.

Model for End-Stage Liver Disease (MELD) score and organ allocation from cadaveric donors for 198 liver transplantation procedures performed in a single center

Since February 2002, the United Network for Organ Sharing (UNOS) proposed to adopt a modified version of the Model for End-Stage Liver Disease (MELD) to assign priority on the waiting list for orthotopic liver transplantation (OLT). In this study, we evaluated the impact of MELD score on liver allocation in a single center series of 198 liver recipients (mean age of patients, 52.21+/-8.92 years), considering the relationship between clinical urgency derived from MELD score (overall MELD, 18.7+/-6.83; MELD <15 in 69 patients, MELD >or=15 in 129 patients) and geographical distribution of cadaveric donors (inside/outside Liguria Region, 125/73). The waiting time for OLT was 230+/-248 days, whereas the 3-month and 1-year patient survivals were 87.37% and 79.79%, respectively. No difference was observed for MELD score retrospectively calculated for patients who underwent OLT before February 2002 (n=71) compared with MELD score calculated for patients who received a liver thereafter (18.26+/-6.68 vs 18.94+/-6.92; P= .504). No significant difference was found in waiting time before and after adoption of MELD score (213+/-183 vs 238+/-278 days; P= .500), or by stratifying patients for MELD <15/>or=15 (225+/-234 vs 232+/-256 days; P= .851). Using the geographical distribution of donors as a grouping variable (outside vs inside Liguria Region), no significance occurred for MELD score (19.68+/-7.42 vs 18.17+/-6.42; P= .135) or waiting time (211+/-226 vs 242+/-261 days; P= .394). In our series, more OLTs were performed among sicker patients and no differences were found in the management of livers procured from cadaveric donors outside or inside Liguria Region. However, further efforts are needed to reduce the waiting time among patients with higher MELD scores.

Predictors of mortality of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF), a disease with histological features corresponding to usual interstitial pneumonia (UIP), is a disorder of unknown cause. Not only it is the most common subtype of idiopathic interstitial pneumonias but it is also associated with the highest mortality rate. Despite a good number of studies investigating the mortality of patients with UIP the prognostic factors that have been studied have several limitations. To date it is unclear when in the course of the disease and with what modality these patients should be treated. According to the literature we subcategorized predictors of mortality into (a) baseline predictors; (b) dynamic predictors. IPF perspectives in therapy have been also analyzed. Moreover, the principal aims of this review were: (1) to analyze and to clarify the clinical utility of different prognostic factors for IPF; (2) to enable clinicians to better evaluate the eligibility criteria for lung transplantation in the clinical practice.

Medical report type in liver transplantation as a quality system document: new prospects for computerization

The usage of a computerized system to organize data and ease the activity procedures of liver transplantation is useful in clinical transplantation. Preliminary cognitive research on systems of clinical transplantation database concerning medical reports was performed to verify their development level. The survey highlighted that, so far, there has been no experimentation that can be applied to a medical report type devoted to liver transplantation. Regulations in force substantially point out that the medical report ought to contain all items that have to be taken into account in handling the patient from pretransplantation to follow-up. The Department of Transplantation of Genoa chose its medical report model for liver transplantation. The medical report model included the following items: personal data; case history; diagnosis; initial examination for prelisting; fitness for transplantation; assistance context; clinical data including subjective, objective, and instrumental parameters; pharmacological therapies; informed consent, evaluation of fitness; nursing data; counseling and clinical evaluations according to protocols and guidelines of the national transplantation centers. If the computing is well trained, it is supposed to help maintain a whole data view provided it is supplied information in an adequate way. Immediate clinical procedural advantages and useful scientific observations may be obtained from a high-quality database. In fact, all functions have to be applied to specific clinical, administrative needs to be remotely shared and conveniently integrated with each other to make the liver transplantation medical report an easy and handy instrument for inputting and handling data. It must be a precise, complete instrument that may be accessible in real time from any site connected with the intranet network, be unchangeable, and be protected to ensure certification and forensic medicine value.

Split liver transplantation for acute Wilson's disease: new option for urgent recipient?

Wilson's disease is a rare metabolic disorder that may lead to fulminant hepatitis and subsequent liver failure. Herein, we present a case of split liver transplantation performed on a patient with acute Wilson's disease. A 27-year-old female with acute presentation of Wilson's disease and advanced neurological impairment, received a Right Split liver Graft (Segments: IV, V, VI, VII and VIII) transplant. The graft was obtained by an in situ splitting technique. The graft implantation was performed in a standard fashion. No acute rejection episodes of the organ occurred. The postoperative course was uneventful. The graft function, ceruloplasmine level and copper levels progressively normalized. The patient totally recovered from neurological symptoms and the Kayser-Fleischer rings disappeared within one month. At 13 months of follow-up, the patient presented with no symptoms and in good condition. The current literature reports high preoperative mortality rate in patients that underwent partial liver graft for acute hepatic failure. However, our experience indicates that in situ split technique of liver may be a feasible and effective alternative to whole graft transplantation in urgent cases. Moreover, to our knowledge, this is the first successfully case of in situ split liver transplantation for acute Wilson's disease described in literature.

Secondary pulmonary hypertension--diagnosis and management

Secondary pulmonary hypertension (SPHtn) is generally attributable to abnormalities in structure or function of the heart or lung parenchyma. While often defined as a physiologic parameter, pulmonary hypertension (PHtn) can be a major contributor to death and disability in cardiopulmonary diseases. Both detection and management are a challenge. We will review the pathophysiology, diagnostic tools, and treatment strategies in SPHtn with an emphasis on cor pulmonale associated with chronic obstructive pulmonary disease (COPD), pulmonary vasculopathies, and pulmonary embolus. The pathophysiology and common etiologies of SPHtn can be divided into three major categories: (1) elevated pulmonary venous pressure (LV failure and mitral valve disease), (2) pulmonary vascular occlusive disease with or without pulmonary parenchymal disease (pulmonary emboli, COPD, connective tissue diseases), and (3) hypoxemia (sleep apnea). The echo-Doppler is a simple cost-effective tool for detecting PHtn, evaluating right ventricular function, and distinguishing common etiologies such as abnormal systolic and diastolic left ventricular function and mitral valve disease. The ventilation-perfusion radionuclide scan can be used to exclude thromboembolic PHtn, but a helical computer tomography with contrast or pulmonary angiography are necessary to distinguish patients that may benefit from a pulmonary thromboendarterectomy. The six minute walk oxygen saturation test is useful as a quantitative measure of functional capacity, prognosis, response to therapy, and oxygen requirement. Treatment strategies in cor pulmonale are tailored to the specific diagnosis, but generally include proper nutrition, exercise, oxygen supplementation, medications such as digoxin, diuretics, anti-coagulation, and pulmonary vasodilator therapy in selected patients.

Impact of Different Cadaveric Donor Age Cut-Offs on Adult Recipient Survival After Liver Transplantation: A Single-Center Analysis

The increase in the number of patients awaiting liver transplantation (OLT) has forced the use of cadaveric donors (CD) with suboptimal characteristics. Of these, donor age is perhaps the most investigated parameter. Although excellent outcomes were observed for OLT using CD aged over 60 years, the European Liver Transplant Registry (ELTR) Group found an increased risk by using CD of more than 55 years. The Italian National Transplant Center has recently assumed that CD age more than 60 years is a potential risk factor for OLT. In this study, a single-center analysis was performed by stratifying CD by three age cut-offs (< or =55 or >55, < or =60 or >60, and < or =65 or >65 years) to evaluate effects on OLT outcome. Although no significant difference in 6-month and 1-year patient or graft survival occurred after stratification for each donor age cut-off, a better survival was observed with OLT performed using livers procured from CD >55 years. A significant increase in cold ischemia time (CIT) was observed among OLT performed with grafts procured from CD < or =55 and < or =65 years (P = .007), and there was an inverse correlation between overall CIT and donor age (R = -0.300; P = .0022). However, no impact on 1-year patient survival was observed by introducing CIT in univariate logistic regression models as well as donor age, recipient age, donor/recipient age ratio, donor/recipient sex mismatch, ELTR diagnostic categories, and UNOS status. The results of this study suggest the suitability of CD of more than 55 years for OLT and the need to further investigate the cut-off value for CIT-related risk.

Simultaneous liver-kidney transplantation for glycogen storage disease type IA (von Gierke's disease)

INTRODUCTION

Glycogen storage disease type Ia (GSDIa) is due to the deficiency of glucose-6-phosphatase activity in the liver, kidney, and intestine. Although significant progress has been achieved in the management of patients with GSDIa, complications still emerge. The potential for development of liver adenomatosis and kidney failure makes these patients candidates for simultaneous liver-kidney transplantation (SLKT). Herein, we describe such a transplantation in a patient affected by this rare storage disease.

METHODS

A 25-year-old female patient with GSDIa developed hepatic adenoma and kidney failure despite dietary therapy. The patient underwent an SLKT from a cadaveric donor.

RESULTS

The operative time was 8 hours without hemotransfusion. Only a transitory lactic acidosis was observed. Laboratory results normalized on postoperative day 7. The patient was discharged on postoperative day 9. After 4 months, the patient is in good condition with well-functioning kidney and liver allografts.

CONCLUSION

Patients with end-stage renal disease secondary to GSDIa should be considered for SLKT, especially when the disease is in an early stage.

Bronchial hyperresponsiveness in asthmatic adults--a long-term correlation study

BACKGROUND

Bronchial hyper responsiveness (BHR), is a risk factor for asthma. It is a state in which excessive narrowing of the airways occurs in response to varying stimuli. BHR seems to be due to the interaction of multiple factors and its relation to asthma is complex. Asthma without BHR is unusual. Indeed, patients who show a higher degree of symptoms have higher levels of BHR. To date no study has investigated the correlation between BHR in mild persistent asthmatic adults and a long-term therapy of five years. The aim of this study is to evaluate (i) the role of BHR in the clinical evaluation of asthma, (ii) the correlation between BHR and therapy in asthma.

METHODS

Seventy patients (were recruited 34 men, age 21-55 years) suffering from: (a) mild seasonal allergic asthma (17/70), (b) mild perennial allergic asthma (34/70) and (c) mild non-allergic [corrected] asthma (19/70). 14 patients from group (a) and 28 patients from group (b) were treated with inhaled beta2-agonists, beclomethasone, disodiumcromoglycate and immunotherapy. 14 patients from group (c) underwent the same treatment regimen without immunotherapy. All patients were evaluated with a metacholine challenge test. The BHR (PD20 FEV1) was calculated at baseline and after a two-year symptom free period. Fifteen pts were followed-up for five years with an evaluation every year. All other patients did not receive any treatment. The results (expressed as mean +/- SE) were evaluated.

RESULTS

Fourteen pts and three pts from group (a) showed a mean BHR value of 984 +/- 3.66 and 674 +/- 2.06; 343 +/- 7.60 and 208 +/- 7.70 respectively. The results were not statistically significant Twenty-eight and six pts from group (b) showed mean values of 685 +/- 1.45 and 1405 +/- 5.65; 856 +/- 7.09 and 435 +/- 2.20 with apparent improvement for the former. Five pts and fourteen pts from group (c) showed mean value of 2682 +/- 7.85 and 2099 +/- 6.82; 816 +/- 2.53 and 877 +/- 4.78 respectively. As for the 5-yr follow up ten pts and five pts from group (b) showed mean values of 705 +/- 1.6 and 861 +/- 7.15; 911 +/- 7.3 and 457 +/- 2.3 respectively.

CONCLUSIONS

Although the clinical picture improved with therapy, BHR was not significantly affected in any patient group, at two and five years of follow-up. Furthermore, no correlation was found between the clinical picture and PD20 FEV1 values. BHR seems to result from the interaction of multiple factors that are worth further investigating. BHR cannot be considered a marker of disease activity in asthma and therefore is not a useful tool for guiding asthma therapy.

Potential predictive value of the MELD score for short-term mortality after liver transplantation

In the last years, a model for end-stage liver disease (MELD) was suggested as a disease severity score for patients with end-stage liver disease awaiting liver transplantation. In the early 2002, United Network for Organ Sharing (UNOS) has proposed to replace the current status 2A, 2B, and 3 by a modified version of the original MELD score based upon patient risk for 3-month mortality on the waiting list. In this study UNOS status and MELD score were evaluated retrospectively for postoperative 3-month mortality in patients who underwent liver transplantation from 2000 to 2001. Liver recipients were stratified for UNOS status 2A, 2B, and 3, and the corresponding MELD score was calculated for each patient. A receiver operating characteristic (ROC) analysis was performed for both conventional UNOS status and MELD score by fitting patient deaths within 3 months after liver transplantation. The MELD score revealed a better prediction rate for 3-month mortality after the first LT than conventional UNOS status, although no statistical significance was evident by ROC curve comparison. This preliminary study seems to suggest a potentially better predictive rate for the MELD score than conventional UNOS status concerning short-term mortality after liver transplantation.

Split liver transplantation in Italy

The role of split liver transplantation has been well established. The limitation to this technique is the number of potential recipients for a left lateral segment graft. The optimal use of the donor pool is to split the liver to provide 2 grafts suitable for adults obtaining right or left lobe. We explored the potential increase in the number of liver grafts gained from systematically using the technique of splitting on national basis. The crucial factor appeared to be creation of guidelines for the use of optimal livers to optimize organ allocation while minimizing pretransplantation mortality and maximizing post-orthotopic liver transplantation outcome.

Octreoscan perspectives in sarcoidosis and idiopathic interstitial pneumonia

STUDY OBJECTIVES

Clinical, radiological, and serological tests have been proven to be unsatisfactory as markers of activity in sarcoidosis and idiopathic interstitial pneumonia (IIP). We investigated 111In-Octreotide (Octreoscan) scintigraphy as a tool for classifying and assessing disease activity in sarcoidosis and IIP, in comparison of the radiological imaging and dyspnea symptom scores.

PATIENTS

Thirty-three patients (pts) of which 16 with sarcoidosis (mean age 43.6, range 30-58 years) and 17 with histologically diagnosed IIP (mean age 62.2, range 35-79 years), were enrolled in the study. Clinical history was taken as well as, physical examination, chest X-ray and pulmonary function tests were assessed. A high-resolution computed tomography scan (HRCT) was carried out in-patients affected by sarcoidosis, who had a normal chest X-ray, and in IIP patients. Both groups were evaluated with the Octreoscan uptake index (U.I.; normal value: < or = 10).

RESULTS

In patients affected with sarcoidosis, the Octreoscan U.I. was significantly higher than in patients with IIP (16.35 +/- 3.1 and 10.06 +/- 0.8, respectively; p < 0.01) and was correlated with the radiographic staging (p < 0.01) and with the degree of dyspnea (p < 0.01). In-patients with IIP the Octreoscan uptake index was slightly above the normal limit (range 10.3-11.7) in non-specific interstitial pneumonia (NSIP) and desquamative interstitial pneumonia (DIP), whereas in usual interstitial pneumonia (UIP) Octreoscan uptake index was always within normal limit (< or = 10 U.I.). A negative correlation was observed with histological findings (p < 0.01) and with HRCT appearance (p < 0.01).

CONCLUSIONS

Octreoscan U.I. is correlated with the degree of dyspnea in patients affected by sarcoidosis and can quantify more accurately the degree of pulmonary involvement, as compared to radiological assessment. Further studies are necessary to evaluate Octreoscan as an early test for predicting disease progression. Octreoscan U.I. could be helpful in monitoring IIP in specific histological subsets (NSIP and DIP) and substitute HRCT in the assessment of UIP for its excellent accuracy.

Neurotensin pulmonary metabolism in normal and asthmatic subjects

BACKGROUND

The role of pulmonary metabolism of endogenous neurotensin (NT) in asthma is still unclear. Information on this subject in humans is scarce.

OBJECTIVES

Evaluation of the pulmonary metabolism of the endogenous NT in asthmatic subjects during symptom-free periods and after a methacoline challenge test and in healthy individuals.

METHODS

Ten asthmatic subjects (aged 34 to 70 years), diagnosed with extrinsic (n = 5), atopic (n = 3), and mixed asthma (n = 2), were compared to a group of 10 healthy individuals (aged 45 to 69 years). The asthmatic group of patients was evaluated with a PD20-FEV1 methacoline challenge test 3 days after a washout period from cessation of their regular medications. Two catheters were inserted in order to draw blood samples for the evaluation of NT concentration: one was inserted into the pulmonary artery and the other into the radial artery. The mean concentration of NT in pulmonary and systemic arterial blood, as well as the arteriovenous difference of NT and the absolute value of production rate [PR/m'], PR/m'/kg and PR/m'/m2 were calculated for each participant.

RESULTS

The mean neurotensin concentration in normal subjects was higher in mixed venous blood (pulmonary artery) than in systemic arterial blood (p < 0001). Similarly, mean NT mixed venous levels in asthmatic subjects was shown to be higher than mean NT levels in systemic arterial blood, before and after the bronchoconstriction with methacoline (p = 0.05 and p = 0.02, respectively). In contrast, the arterovenous difference and the mean values of PR of NT were similar in both groups.

CONCLUSIONS

Our findings suggest that (1) NT concentration in mixed venous blood changes in transit through the pulmonary parenchyma, indicating that the pulmonary parenchyma is an important site of NT metabolism; (2) Pulmonary clearance of NT is unaffected by cholinergic bronchoconstriction. Further clinical studies are needed in order to improve both the understanding and the therapeutic approach of the neurogenic process in asthmatic subjects.

Hyperresponsiveness of airway muscle to acetylcholine in asthmatic and non-asthmatic subjects

BACKGROUND

Despite a long-standing recognition, the bronchial hyperresponsiveness (BHR) of airway smooth muscle, in asthmatic and non-asthmatic subjects is still under investigation.

OBJECTIVE

In order to better understand the mechanism regulating the airway function, some results obtained with cellular physiology techniques are compared, for some non-asthmatic without BHR subjects and other subjects suffering from real bronchial asthma.

SUBJECTS

Eighteen subjects without chronic or acute bronchopathy and seven patients with a typical history of bronchial asthma were considered. All of them were non-smokers, with a wide range of in vivo hyperresponsiveness to Acetylcholine (ACh). Owing to neoplastic lesions, all patients underwent a thoracic surgery.

MEASUREMENTS AND RESULTS

In vitro hyperresponsiveness of airway-smooth-muscle chains was assessed with isotonic contractions to incremental doses of ACh, in accordance with a non-cumulative dose-response technique. Regression between muscle contractions and ACh doses was studied for both groups, and it turned out to be linear in both cases. The slopes and elevations of the regression lines of the two groups were statically identical. There was no correlation between in vivo hyperresponsiveness (as PD20-ACh-FEV1) and in vitro responses (as EC50), for both asthmatic and non-asthmatic group.

CONCLUSIONS

(i) in vitro, the same BHR of smooth-muscle resulted, for both asthmatic and non-asthmatic subjects, (ii) in vivo, a different BHR of the former group resulted. This can be explained with the peculiarity of the micro-environmental surrounding the bronchial tissue, not with an intrinsic defect of the isolated bronchial tissue.

Effect of low-dosage recombinant human growth hormone therapy on pulmonary function in hypopituitary patients with adult-onset growth hormone deficiency

An impairment of the pulmonary function has been described in adult patients with childhood-onset growth hormone deficiency (GHD). We examined forced vital capacity (FVC), forced expiratory volume (FEV1), total lung capacity (TLC), functional residual capacity (FRC), residual volume (VR) and the index of inspiratory strength, middle tidal volume and tidal inspiratory time ratio (TV/I), in 29 patients with adult-onset GHD. Data were compared with those obtained in 46 healthy control subjects. Only the FEV1/FVC ratio was statistically different (p = 0.04) between the two groups of subjects. In a group of 15 GHD patients low dosages (0.5-1 IU/day s.c., bedtime) of recombinant human GH (rh-GH; n. = 8 subjects) or placebo (n. = 7) were given at random for a 6-month period. A significant increase in IGF-I levels was noted in the rh-GH-treated group (p = 0.04) but not in the placebo group. After the 6-month period no statistically significant changes in pulmonary function were found between the rh-GH-treated and placebo-treated GHD patients. This study shows that adult-onset GHD patients suffer from minimal impairment of pulmonary function. Low rh-GH dosages able to induce an increase in IGF-I levels do not improve pulmonary function. The effect of rh-GH on respiratory muscle strength could be related to the age at which GHD diagnosis is made, or induced only by high rh-GH dosages given for a long time.

[Syringomyelia and pregnancy. Report of a clinical case and review of the literature]

The authors describe a case of pregnancy in a patient previously affected by Arnold-Chiari malformation associated with syringomyelia; from clinical experience and a review of the literature, the possibility is deduced of carrying out the pregnancy physiologically, although by observing close precaution while performing delivery which, by our experience, should be accomplished by partus caesarius in general anaesthesia, taking great care to the evaluation of neurologic parameters.

[Pulmonary metabolism of beta-endorphin in asthmatic patients in asymptomatic periods and after bronchospasm induced by methacholine]

Blood concentration of endogenous beta-endorphines can change during the clinical evolution of chronic bronchopneumopathies. The authors assessed the beta-endorphine concentrations in the pulmonary arterial and systemic arterial blood in 8 asthmatic patients during a symptom-free period and after methacholine-induced bronchospasm. The beta-endorphine analysis was performed in duplicate dor each sample, by means of a RIA assay. There is not difference in the systemic arterial blood concentration of beta-endorphines between asthmatic patients and normal subjects. Furthermore, there is no change in the beta-endorphine blood concentration during the passage through the pulmonary tissue after methacoline-induced bronchospasm.

The association of thrombocytopaenia and Lyme disease

The association of asymptomatic thrombocytopaenia in six patients with acute Lyme disease is described. Recovery from thrombocytopaenia occurred shortly following antibiotic therapy. Patients residing in endemic areas for Lyme disease who present with flu-like symptoms and laboratory findings of thrombocytopaenia should prompt suspicion of acute Lyme disease. Appropriate clinical studies should be undertaken to confirm the diagnosis.

Elective hepatic resection for benign and malignant liver disease: early results

Between August 1989 and April 1992, 60 consecutive elective hepatic resections were performed by one surgeon at two hospitals. This personal series was reviewed to determine the early results of elective hepatic resection. There were 17 patients with liver metastases from colorectal cancer, 14 with hepatocellular carcinoma (three with cirrhosis), seven with cholangiocarcinoma, six with carcinoma of the gallbladder plus liver involvement, ten with liver metastases from other sites and six with benign conditions of the liver. Thirty-eight patients underwent major liver resection, seven unisegmentectomy, six bisegmentectomy, four trisegmentectomy and five non-anatomical resection. Total vascular exclusion was used in 50 cases and the Pringle manoeuvre in ten. The mean(s.d.) operative blood transfusion was 990(1260) ml packed red blood cells (range 0-13 units); 17 patients did not receive blood transfusion. There were two operative deaths; non-fatal complications developed in 16 patients. The two deaths were from postoperative liver failure and there was no other hospital death.

[Use of nabumetone in the treatment of primary dysmenorrhea. Report of 100 cases]

The aim of the study was to assess the efficacy and tolerability of nabumetone, a new nonsteroid anti-inflammatory agent with analgesic and antipyretic functions, in the treatment of primary dysmenorrhea in 100 patients. Treatment was administered at a dose of 1 g per day for slight and moderate cases and 2 g per day for severe forms, starting from the onset of painful symptoms and lasting while they persisted. Side effects were observed in 7% of cases but were limited to the gastroenteric tract. The analysis of results confirms that with regard to the remission of symptoms, treatment was efficacious from the second month and that a further improvement was obtained with continued treatment. However, the Authors observed that, although the remission of symptoms was partial in the majority of cases, there was a greater response in cases of moderate or severe dysmenorrhea and their duration was shorter in comparison to those months in which patients had not received nabumetone treatment.

[Use of phytostimolin vaginal cream and lavage in cervical dystrophy after DTC of the cervix]

The study evaluated the efficacy and tolerance of the active components of "phytostimolin" cream and vaginal lavage, Triticum Vulgare and Ether glycoethylen-mono-phenolic, in 40 patients suffering from dystrophic cervico-vaginal pathologies (group 1), and in 20 patients following DTC of the portio due to ectropion (group 2). The study was double blind. An overall efficacy of 70% was observed in group 1 and 90% in group 2. The results obtained, the absence of side effects, and the good level of tolerance confirm the value of the above components in the pathology in question.

[The use of ferritin in 40 patients with iron deficiency of various degrees caused by gynecologic disorders]

The authors evaluated the efficacy and tolerability of treatment with ferritin in 40 cases of iron deficiency because of gynecological pathology. After 2 months of therapy, 80% of patients showed a normalization of laboratory examinations while after 4 months both the normalization of laboratory examinations and the clinical symptomatology, were demonstrated in all cases. Only 7.5% of cases were very light and did not show remarkable adverse. It is concluded that this can be used safely.

[Endometriosis of the lower abdominal wall. Report of two cases secondary to cesarean section]

The paper describes two cases of cutaneous endometriosis in correspondence with the surgical scar following cesarean section. The cases formed part of a series of 500 abdominal operations performed during the period 1988-89, of which about 200 were cesarean sections, with a 1% frequency. In line with the hypothesis regarding the spread of endometrial tissue during surgery and with that concerning peritoneal metaplasia, the authors recommend paying special attention during the technical procedure of extracting the fetus, and performing an introflexed suture of the uterine incision and of the parietal peritoneum.

[Comparison of fluconazole and ketoconazole in the therapy of vaginal candidiasis by administration in two different oral doses]

The authors examined 20 patients affected by vaginal candidiasis and evaluated the efficacy and tolerability of treatment with Fluconazole in comparison with Ketoconazole, using two different doses of oral administration: Fluconazole, 150 mg in a single dose; Ketoconazole, 400 mg/die for 5 days. There were no significant differences in results; adverse effects were insignificant and the level of efficacy, which was the same in both cases, was high. In conclusion, both molecules are confirmed to be efficacious, although patients showed a preference for the single dose and for only one day of therapy.

[Variations of vasoactive intestinal peptide (VIP) concentration in the lung of asthmatic patients]

The vasoactive intestinal peptide (VIP) concentrations in the pulmonary and systemic arterial blood were evaluated in 11 asthmatic patients in symptom-free period and during methacholin induced broncospasm. The basal venous and arterial mean values do not significantly differ. A significant difference was observed after bronchial challenge. This could be caused by an increased VIP pulmonary production as a defensive mechanism. No correlation was found between bronchial reactivity (as PD20-FEV1 Methacholin) and VIP concentrations.

[A case of pulmonary embolism after cesarean section]

The authors describe a case of pulmonary embolism occurred to a young woman (24 years old) after a Cesarean operation. All the evolving stages of the disease are examined till to the complete recovery of the patient. They conclude underlining the importance of an opportune diagnoses and an adequate therapy for a favourable prognoses quoad vitam et valetitudinem.

[Use of ofloxacin in 45 cases of infection of the lower urinary tract in women]

Forty-five female patients affected by lower urinary tract infections without secondary complications were examined. Ofloxacin was administered in three different dosages in order to evaluate drug efficacy and tolerance: 600 mg/day for 3 days in 22 cases; 300 mg/day for 3 days in 22 cases; 600 mg/day for 5 days in 1 case. Adverse effects were insignificant; clinical remission was virtually complete and urine tests proved negative in 98% of cases. On the basis of these findings it is possible to state that Ofloxacin therapy is efficacious in lower urinary tract infections without secondary complications in women.

Some effects of prolonged treatment with nicardipine in chronic bronchial asthma

A study was carried out in 10 patients with chronic non-severe asthma to investigate the effects of prolonged treatment with the calcium blocker, nicardipine. Patients received 60 mg nicardipine daily for 3 months. Measurements were taken before and after treatment of FEV1, PaO2 and PD20 his. The results showed no statistically significant effect on FEV1. Although there was a statistically significant decrease in PaO2 this was not important clinically. There was a statistically significant increase in PD20 his, demonstrating the protective effect of nicardipine on histamine-induced bronchoconstriction. Breathlessness was reduced in 70% of the patients and the drug was well tolerated throughout the study.

[The nonadrenergic noncholinergic system in the regulation of bronchial tonus]

Bronchial release appears to be regulated by the nonadrenergic noncholinergic system whose transmitter is very probably VIP. In vivo and in vitro studies were conducted to discover whether peptide modifies basic function and/or bronchial spasm provoked by histamine. The data collected show that VIP failed to cause bronchodilation but protects against histamine induced bronchoconstriction both in vivo and in vitro.