Evaluation and Management of Deficiency of Adenosine Deaminase 2: An International Consensus Statement

Importance

Deficiency of adenosine deaminase 2 (DADA2) is a recessively inherited disease characterized by systemic vasculitis, early-onset stroke, bone marrow failure, and/or immunodeficiency affecting both children and adults. DADA2 is among the more common monogenic autoinflammatory diseases, with an estimate of more than 35 000 cases worldwide, but currently, there are no guidelines for diagnostic evaluation or management.

Objective

To review the available evidence and develop multidisciplinary consensus statements for the evaluation and management of DADA2.

Evidence Review

The DADA2 Consensus Committee developed research questions based on data collected from the International Meetings on DADA2 organized by the DADA2 Foundation in 2016, 2018, and 2020. A comprehensive literature review was performed for articles published prior to 2022. Thirty-two consensus statements were generated using a modified Delphi process, and evidence was graded using the Oxford Center for Evidence-Based Medicine Levels of Evidence.

Findings

The DADA2 Consensus Committee, comprising 3 patient representatives and 35 international experts from 18 countries, developed consensus statements for (1) diagnostic testing, (2) screening, (3) clinical and laboratory evaluation, and (4) management of DADA2 based on disease phenotype. Additional consensus statements related to the evaluation and treatment of individuals with DADA2 who are presymptomatic and carriers were generated. Areas with insufficient evidence were identified, and questions for future research were outlined.

Conclusions and Relevance

DADA2 is a potentially fatal disease that requires early diagnosis and treatment. By summarizing key evidence and expert opinions, these consensus statements provide a framework to facilitate diagnostic evaluation and management of DADA2.

The Role of Continuous Theta Burst TMS in the Neurorehabilitation of Subacute Stroke Patients: A Placebo-Controlled Study

Objectives: Transcranial magnetic stimulation, in particular continuous theta burst (cTBS), has been proposed for stroke rehabilitation, based on the concept that inhibition of the healthy hemisphere helps promote the recovery of the lesioned one. We aimed to study its effects on cortical excitability, oscillatory patterns, and motor function, the main aim being to identify potentially beneficial neurophysiological effects. Materials and Methods: We applied randomized real or placebo stimulation over the unaffected primary motor cortex of 10 subacute (7 ± 3 days) post-stroke patients. Neurophysiological measurements were performed using electroencephalography and electromyography. Motor function was assessed with the Wolf Motor Function Test. We performed a repeated measure study with the recordings taken pre-, post-cTBS, and at 3 months' follow-up. Results: We investigated changes in motor rhythms during arm elevation and thumb opposition tasks and found significant changes in beta power of the affected thumb's opposition, specifically after real cTBS. Our results are consistent with an excitatory response (increase in event-related desynchronization) in the sensorimotor cortical areas of the affected hemisphere, after stimulation. Neither peak-to-peak amplitude of motor-evoked potentials nor motor performance were significantly altered. Conclusions: Consistently with the theoretical prediction, this contralateral inhibitory stimulation paradigm changes neurophysiology, leading to a significant excitatory impact on the cortical oscillatory patterns of the contralateral hemisphere. These proof-of-concept results provide evidence for the potential role of continuous TBS in the neurorehabilitation of post-stroke patients. We suggest that these changes in ERS/ERD patterns should be further explored in future phase IIb/phase III clinical trials, in larger samples of poststroke patients.

Microbleeds and the Effect of Anticoagulation in Patients With Embolic Stroke of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Randomized Clinical Trial

Importance

The reported associations of cerebral microbleeds with recurrent stroke and intracerebral hemorrhage have raised concerns regarding antithrombotic treatment in patients with a history of stroke and microbleeds on magnetic resonance imaging.

Objective

To characterize microbleeds in embolic strokes of undetermined source (ESUS) and report interactions between microbleeds and the effects of random assignment to anticoagulant vs antiplatelet therapy.

Design, Setting, and Participants

Subgroup analyses of the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs Aspirin to Prevent Embolism in ESUS (NAVIGATE ESUS) international, double-blind, randomized, event-driven phase 3 clinical trial. Participants were enrolled between December 2014 and September 2017 and followed up for a median of 11 months. The study setting included 459 stroke recruitment centers in 31 countries. Patients aged 50 years or older who had neuroimaging-confirmed ESUS between 7 days and 6 months before screening were eligible. Of these 7213 NAVIGATE ESUS participants, 3699 (51%) had information on cerebral microbleeds reported on their baseline clinical magnetic resonance imaging and were eligible for these analyses. Patients with a prior history of symptomatic intracerebral hemorrhage were excluded from the NAVIGATE ESUS trial.

Interventions

Rivaroxaban, 15 mg, compared with aspirin, 100 mg, daily.

Main Outcomes and Measures

The primary outcome was recurrent stroke. Secondary outcomes were ischemic stroke, intracerebral hemorrhage, and all-cause mortality.

Results

Microbleeds were present in 395 of 3699 participants (11%). Of patients with cerebral microbleeds, mean (SD) age was 69.5 (9.4) years, 241 were men (61%), and 201 were White (51%). Advancing age (odds ratio [OR] per year, 1.03; 95% CI, 1.01-1.04), East Asian race/ethnicity (OR, 1.57; 95% CI, 1.04-2.37), hypertension (OR, 2.20; 95% CI, 1.54-3.15), multiterritorial infarcts (OR, 1.95; 95% CI, 1.42-2.67), chronic infarcts (OR, 1.78; 95% CI, 1.42-2.23), and occult intracerebral hemorrhage (OR, 5.23; 95% CI, 2.76-9.90) were independently associated with microbleeds. The presence of microbleeds was associated with a 1.5-fold increased risk of recurrent stroke (hazard ratio [HR], 1.5; 95% CI, 1.0-2.3), a 4-fold risk of intracerebral hemorrhage (HR, 4.2; 95% CI, 1.3-13.9), a 2-fold risk of all-cause mortality (HR, 2.1; 95% CI, 1.1-4.3), and strictly lobar microbleeds with an approximately 2.5-fold risk of ischemic stroke (HR, 2.3; 95% CI, 1.3-4.3). There were no interactions between microbleeds and treatment assignments for recurrent stroke, ischemic stroke, or all-cause mortality. The HR of intracerebral hemorrhage on rivaroxaban was similar between persons with microbleeds (HR, 3.1; 95% CI, 0.3-30.0) and persons without microbleeds (HR, 3.0; 95% CI, 0.6-14.7; interaction P = .97).

Conclusions and Relevance

Microbleeds mark an increased risk of recurrent stroke, ischemic stroke, intracerebral hemorrhage, and mortality in ESUS but do not appear to influence effects of rivaroxaban on clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02313909.

Impact of Post-Stroke Recanalization on General and Upper Limb Functioning: A Prospective, Observational Study

The objective of this study is to assess the impact of recanalization (spontaneous and therapeutic) on upper limb functioning and general patient functioning after stroke. This is a prospective, observational study of patients hospitalized due to acute ischemic stroke in the territory of the middle cerebral artery (n = 98). Patients completed a comprehensive rehabilitation program and were followed-up for 24 weeks. The impact of recanalization on patient functioning was evaluated using the modified Rankin Scale (mRS) and Stroke Upper Limb Capacity Scale (SULCS). General and upper limb functioning improved markedly in the first three weeks after stroke. Age, gender, and National Institutes of Health Stroke Scale (NIHSS) score at admission were associated with general and upper limb functioning at 12 weeks. Successful recanalization was associated with better functioning. Among patients who underwent therapeutic recanalization, NIHSS scores ≥16.5 indicate lower general functioning at 12 weeks (sensibility = 72.4%; specificity = 78.6%) and NIHSS scores ≥13.5 indicate no hand functioning at 12 weeks (sensibility = 83.8%; specificity = 76.5%). Recanalization, either spontaneous or therapeutic, has a positive impact on patient functioning after acute ischemic stroke. Functional recovery occurs mostly within the first 12 weeks after stroke, with greater functional gains among patients with successful recanalization. Higher NIHSS scores at admission are associated with worse functional recovery.

Genetic architecture of common non-Alzheimer's disease dementias

Frontotemporal dementia (FTD), dementia with Lewy bodies (DLB) and vascular dementia (VaD) are the most common forms of dementia after Alzheimer’s disease (AD). The heterogeneity of these disorders and/or the clinical overlap with other diseases hinder the study of their genetic components. Even though Mendelian dementias are rare, the study of these forms of disease can have a significant impact in the lives of patients and families and have successfully brought to the fore many of the genes currently known to be involved in FTD and VaD, starting to give us a glimpse of the molecular mechanisms underlying these phenotypes. More recently, genome-wide association studies have also pointed to disease risk-associated loci. This has been particularly important for DLB where familial forms of disease are very rarely described. In this review we systematically describe the Mendelian and risk genes involved in these non-AD dementias in an effort to contribute to a better understanding of their genetic architecture, find differences and commonalities between different dementia phenotypes, and uncover areas that would benefit from more intense research endeavors.

Headache intensity is associated with increased white matter lesion burden in CADASIL patients

OBJECTIVES

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary cause of vascular dementia in adults. Migraine is a major symptom of the disease. We aimed to identify clinical and demographical features of the headache associated with increased cerebral lesion burden in a cohort of CADASIL patients.

METHODS

Thirty-two patients with CADASIL were enrolled in this cross-sectional study. Demographics data, vascular risk factors and headache characteristics were collected through a structured questionnaire. MRI (3-T) was used to determine white matter hyperintensities burden evaluated by its volume (WMH-V).

RESULTS

Regression analysis showed that age (β = 1.266, 95%CI = [0.805, 1.726], p < 0.001), headache intensity (β = 5.143, 95%CI = [2.362, 7.924], p = 0.001) and female sex (β = 19.727, 95%CI = [8.750, 30.075], p = 0.001) were the main predictors of WMH-V.

DISCUSSION

Age, female sex and headache intensity are associated with increased white matter lesion volume in CADASIL.

Abstract 41: Cerebral Microbleeds and the Effect of Anticoagulation on Outcomes in 3699 Patients With Embolic Strokes of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Trial

Background: Cerebral microbleeds (CMBs) are reported to predict recurrent stroke and antithrombotic-related intracerebral hemorrhage (ICH). We characterize CMBs in a well-defined population of embolic strokes of undetermined source (ESUS). Notably, we report for the first time interactions between CMBs and effects of random assignment to anticoagulant therapy.

Methods: Subgroup analyses of the NAVIGATE ESUS randomized trial comparing rivaroxaban 15 mg vs. aspirin 100 mg daily were performed. CMBs were rated on T2*-GRE sequences obtained at baseline MRI in 3699 participants (mean age 67y). Multivariable regression analyses were used to identify variables independently associated with CMBs. Cox proportional hazards models were used to estimate the contribution of CMBs to risk of recurrent stroke, ischemic stroke, ICH and all-cause mortality. Analyses followed the intent-to-treat paradigm.

Results: CMBs were present in 11% of participants. CMBs were strictly deep in 55%, lobar in 26%, and mixed in 19% of cases. Most (68%) had 1-2 CMBs, 27% had 3-10, and 5% >10. Advancing age (OR per yr 1.0, 95% CI 1.01-1.04), East Asian ethnicity (1.6, 1.0-2.4), hypertension (2.2, 1.5-3.2), multi-territorial ESUS (2.0, 1.4-2.7), chronic infarcts (1.8, 1.4-2.2), and occult ICH (5.2, 2.8-9.9) were independently associated with CMBs. During a median follow-up of 11 months, 5.1% of participants had recurrent stroke (4.8% ischemic stroke; 0.3% ICH) and 1.3% died. The presence of CMBs was associated with a 50% increased risk of recurrent stroke (HR 1.5, 95% CI 1.0-2.3), four-fold risk of ICH (4.2, 1.3-13.9), and two-fold risk of all-cause mortality (2.1, 1.1-4.3), and strictly lobar CMBs with a ~2.5-fold risk of ischemic stroke (2.3, 1.3-4.3). There were no interactions between CMBs and treatment assignments for recurrent stroke (p-value for interaction=0.2), ischemic stroke (p=0.3), or all-cause mortality (p=0.6). The hazard ratio (HR) of ICH on rivaroxaban was similar between persons with CMBs (HR 3.1, 95% CI 0.3 - 30.0) and persons without CMBs (HR 3.0, 95% CI 0.6 - 14.7; interaction p=1.0).

Conclusions: CMBs mark an increased risk of recurrent ischemic stroke, ICH and mortality in ESUS, but do not appear to influence effects of rivaroxaban, particularly on the outcome of ICH.

Blood Pressure Variability in Acute Ischemic Stroke: The Role of Early Recanalization

We performed a retrospective study with the aim of investigating the association between blood pressure (BP) variability in the first 24 h after ischemic stroke and functional outcome, regarding arterial recanalization status. A total of 674 patients diagnosed with acute stroke and treated with revascularization therapies were enrolled. Systolic and diastolic BP values of the first 24 h after stroke were collected and their variation quantified through standard deviation. Recanalization state was evaluated at 6 h and clinical outcome at 3 months was assessed by modified Rankin Scale. In multivariate analyses systolic BP variability in the first 24 h post-stroke showed an association with 3 months clinical outcome in the whole population and non-recanalyzed patients. In recanalyzed patients, BP variability did not show a significant association with functional outcome.

Bilateral versus ipsilesional cortico-subcortical activity patterns in stroke show hemispheric dependence

Background Understanding of interhemispheric interactions in stroke patients during motor control is an important clinical neuroscience quest that may provide important clues for neurorehabilitation. In stroke patients, bilateral overactivation in both hemispheres has been interpreted as a poor prognostic indicator of functional recovery. In contrast, ipsilesional patterns have been linked with better motor outcomes. Aim We investigated the pathophysiology of hemispheric interactions during limb movement without and with contralateral restraint, to mimic the effects of constraint-induced movement therapy. We used neuroimaging to probe brain activity with such a movement-dependent interhemispheric modulation paradigm. Methods We used an fMRI block design during which the plegic/paretic upper limb was recruited/mobilized to perform unilateral arm elevation, as a function of presence versus absence of contralateral limb restriction ( n = 20, with balanced left/right lesion sites). Results Analysis of 10 right-hemispheric stroke participants yielded bilateral sensorimotor cortex activation in all movement phases in contrast with the unilateral dominance seen in the 10 left-hemispheric stroke participants. Superimposition of contralateral restriction led to a prominent shift from activation to deactivation response patterns, in particular in cortical and basal ganglia motor areas in right-hemispheric stroke. Left-hemispheric stroke was in general characterized by reduced activation patterns, even in the absence of restriction, which induced additional cortical silencing. Conclusion The observed hemispheric-dependent activation/deactivation shifts are novel and these pathophysiological observations suggest short-term neuroplasticity that may be useful for hemisphere-tailored neurorehabilitation.

Recanalization Modulates Association Between Blood Pressure and Functional Outcome in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Historical stroke cohorts reported a U- or J-shaped relationship between blood pressure (BP) and clinical outcome. However, these studies predated current revascularization strategies, disregarding the recanalization state of the affected arterial territory. We aimed to investigate the relationship between BP in the first 24 hours after ischemic stroke and clinical outcome in patients submitted to intravenous or intra-arterial recanalization treatments.

METHODS

Consecutive patients with acute stroke treated with intravenous thrombolysis or intra-arterial therapies were enrolled in a retrospective cohort study. BP was measured on regular intervals throughout day and night during the first 24 hours after stroke onset. The mean systolic BP and diastolic BP during the first 24 hours post stroke were calculated. Recanalization was assessed at 6 hours by transcranial color-coded Doppler, angiography, or angio-computed tomography. Functional outcome was assessed at 3 months by modified Rankin Scale. Linear and quadratic multivariate regression models were performed to determine associations between BP and functional outcome for the whole population and recanalyzed and nonrecanalyzed patients.

RESULTS

We included 674 patients; mean age was 73.28 (SD, 11.50) years. Arterial recanalization was documented in 355 (52.70%) patients. In multivariate analyses, systolic BP and diastolic BP in the first 24 hours post stroke show a J-shaped relationship with functional outcome in the total population and in the nonrecanalyzed patients. Recanalyzed patients show a linear association with functional outcome (systolic BP: odds ratio, 1.015; 95% confidence interval, 1.007-1.024; P=0.001; R(2) change=0.001; P=0.412 and diastolic BP: odds ratio, 1.019; 95% confidence interval, 1.004-1.033; P=0.012; R(2) change<0.001; P=0.635).

CONCLUSIONS

Systemic BP in the first 24 hours after ischemic stroke influences 3-month clinical outcome. This association is dependent on the revascularization status.

[Primary sclerosing cholangitis in children and adolescents]

Primary sclerosing cholangitis is a disease usually with a poor prognosis with a mean survival of 10-12 years, starting from the time of diagnosis. Among the different populations studied, males predominate in a ratio 2:1 with ages ranging from 20-78 (mean 42 years). This article describes four patients with this syndrome, a child of eight and three adolescents, thirteen and fourteen years old. It is possibly of autoimmune etiology, characterized by stenosis, dilatation and fibrosis involving the intrahepatic and extrahepatic biliary tree. We analyzed laboratory assays, clinical, immunological, laboratory assays, histological and cholangiographic aspects. In conclusion, in this age group perhaps of the small population sample there was no sex predominance, and 50% progressed without jaundice and without hepatomegaly. The serum levels of gamma glutamyltransferases and especially alkaline phosphatase were elevated compared to aminotransferases without increase of the serum auto antibodies. Only one patients displayed the typical histological appearance of primary sclerosing cholangitis. The diagnosis in al was confirmed by typical cholangiographic signs, restricted only to the intrahepatic biliary tree, identified in all those included in this study.

[Diffuse primary malignant mesothelioma in abdominal cavity]

Two cases of diffuse malignant mesothelioma of abdominal cavity were analysed. These tumors arise from the peritoneum and are also found in the parietal and visceral pleura, pericardium and in vaginal tunic. All of them, infra or supra-diaphragmatic, are associated with asbestos exposure in at least 80% of cases. It is difficult to explain how inhaled asbestos induces peritoneal neoplasms. This aspects become very important in the diagnostic, basically why it is done at laparotomy or laparoscopy. When was proceed the biopsy of the lesions, and occasionally by identification of malignant mesothelial cells in ascitic fluid. In this two cases exposed considerations about the advanced phase of diagnostic are made, the diagnostic was performed in the majority of the collected cells, showing the advanced stage of the disease. At that time of diagnosis we observed poor evolution. We call attention to the importance of precancer diagnosis, the best chance to treatment options, always based on surgical resections, radiation or chemotherapy alone or combined. If the radical surgery is not possible, this patients must be treated by chemotherapy or radiotherapy, defined after complete staging of the disease.

[Frantz tumor--report of 2 cases. Therapeutic approach and prognosis]

The authors report two rare pancreatic tumor cases (Frantz's tumor), which were in different evolutionary stages, emphasizing the complexity of a precise anatomopathologic diagnosis and an aggressive surgical approach, whenever possible because the excellent prognosis. They also discuss the clinical manifestation and histological origin, as well as the prognosis factors and a new approach for the liver metastasis.

[Ultrasonically guided needle biopsy in malignant focal solid nodules of the liver]

In the most of the cases, the diagnosis of focal solid hepatic lesions are performed by ultrasonography, computed tomography, magnetic resonance and hepatic angiography imagig. However, the distinction between benign and malignant neoplasias, sometimes is made after liver biopsy. This report is about 32 of these lesions, diagnosed after guided liver biopsy by ultrasonography. The efficacy of this propedeutic method, minimally invasive, is defined emphasizing that there are no mortality and low levels of morbidity.

Cholelithiasis in cirrhotic patients. (Analysis of cholelithiasis among patients with liver cirrhosis in São Paulo, Brazil)

During the past 20 years, several authors have reported increased prevalence of cholelithiasis in liver cirrhosis. This biliary disease has been implicated with the deterioration of liver function, liver disease of alcoholic origin or even the presence of hypersplenism in this patient population. This study analyzes the incidence and possible factors which are responsible for promoting cholelithiasis in cirrhosis. The study included 110 cirrhotic patients of a private center specialized in treating liver diseases. The incidence of cholelithiasis was 27.3% (25.3% in males and 33.3% in females). There was no correlation between liver function defined by Child's classification or through the laboratory examinations (AST, ALT, AP, GGT, PT, Alb, TB, DB, PA) and the presence of gallstones. No evidence was found that the etiology of cirrhosis or the presence/absence of hypersplenism affected the prevalence of cholelithiasis in this population. In conclusion, an increased prevalence of cholelithiasis was verified in this population of cirrhotics but the pathogenesis is still obscure.

[Immunological parameters in the differential diagnosis of ascites secondary to peritoneal carcinomatosis, hepatic cirrhosis, and congestive heart failure]

As a contribution to the study of ascites in patients with liver cirrhosis, congestive heart failure and peritoneal carcinomatosis evaluate in serum and ascites the concentrations of alphafetoprotein, carcinoembryonic antigen and fibronectin, they might suggest a diagnosis for the basic pathology. Forty-seven patients were studied, from whom 23 with cirrhosis, 17 peritoneal carcinomatosis and 7 with congestive heart failure. We conclude that: a) none of the tools usually employed in the analysis of ascitic fluid alone can make the base pathological process responsible for producing ascites; b) fibronectins were more useful for differential diagnosis between cirrhosis and carcinomatosis; c) alpha-fetoprotein and carcinoembryonic antigen were not useful for the definition for differential diagnosis.

[Hepatic hemangiomas. The importance of the image]

In the authors' experience, 0.24% of the patients submitted to liver imaging (ultrasound or computerized tomography) have hemangiomas. These are shown as solid nodular lesions, mostly found by chance. Sometimes they do not appear as typical solid vascular lesions. The authors' experience and the literature are discussed. A clear and concise approach to this benign neoplasm is suggested.

[Chronic active hepatitis and possible relationship with immunosuppressive therapy]

A 54-year-old man with Chagas cardiomyopathy that was submitted to a heart transplantation and five months later presented a progressive increase in liver enzymes. Diagnosis of chronic active hepatitis was confirmed by histopathologic studies. A transitory interruption of treatment with azathioprine and the posterior re-introduction of small doses, as well as the use of lesser amounts of cyclosporin-A improved the clinical and laboratory pictures. Despite several investigations the pathogenesis of hepatitis remained undetermined, although some type of drug injury was presumed to be involved. The eventual role of viruses as the primary inciting event could not be completely ruled out.

[Lipoid cell tumor of the ovary]

The authors show the clinical and histopathological difficulties for the diagnosis of a rare ovarian tumor in a 13 year old girl who had a bone disease called enchondromatosis, and the adequate treatment for this case. Laparotomy was performed with unilateral salpingo-oophorectomy of the left ovary after a detailed study to detect the origin of the pelvic mass, the patient, who had metrorrhagia and pains in the lower abdomen. Three years after surgery, the patient was once again seen in the outpatient clinic with regular catamenia, requesting some oral contraceptives because she had started sexual activity. The authors conclude that the lipid cell tumor of the ovary is difficult to classify and diagnose, and that it is normally benign, and that treatment for this type of tumor, specially in youngsters, in whom one should be concerned with maintaining menstrual and reproductive function, is the unilateral oophorectomy.

[Gastrin changes in the gastric antrum G-cells and in serum gastrin levels after 80% jejunoileal resection in rats]

A study was made of the changes in the cell population producing gastrin of the gastric antrum in rats submitted to resection of 80% of jejunum-ileum. Ninety days after surgery, the animals were killed after a 12 hour nightly fast and the gastric antrum was removed with the objective of specific histological preparations (PAP method) in order to count the G-cells and the blood was taken for serum doses of gastrin. An optical microscope was used to count the cells using a histometric integraded ocular of 42 points and the counting of 10 fields of each histological cut, and the radioimmunoassay method of double antibody was used for the seric dosing of gastrin. Histometry showed a significant drop in the G-cell population of the antrum of enterectomized animals when compared to the control group. Average percentage of G-cells found were 17.55% in the control group and 7.99% in the enterectomized ones. Blood dosing of hormone showed a significant increase of gastrin in the enterectomized animals when compared to controls. Average value of gastrin dosing the control group was 110 Pg/ml and 170 Pg/ml in enterectomized animals. Therefore, the present study permits to conclude that after resection of 80% of jejunum-ileum, there was a decrease in the G-cell population with gastrin in the gastric antrum even in the presence of increased serum gastrin.

[Diagnosis of hepatocellular carcinoma performed by searching for serologic tumor markers]

Serum levels of alkaline phosphatase, gamma-glutamyltranspeptidase, -1 fucosidase and glutathione-S-transferase are increased in 60, 90, 75 and 64% of patients with hepatocellular carcinoma. In these patients the mean plasma fibrinogen levels is 461.78 mg/dl, while mean serum copper is 200.50 mg/dl. Serum levels of desgamma-carboxiprothrombin is over 900 mg/dl in 67% of the patients (60% of them have HB virus, mostly anti HBe positive). Forty to 95% of them have increased levels of -fetoprotein (AFP). The authors suggest that cirrhotic patients, with or without HB virus, specially those with increased AFP, should have ultrasound examination of the liver every 6 months. This method of imaging has been shown to be more sensitive than AFP (72% versus 25%) in the detection of hepatocellular carcinoma smaller than 2 cm in diameter.

[Hepatocyte necrosis and intrahepatic cholestasis in the postoperative period of patients undergoing heart surgery with the use of extracorporeal circulation: significance of clinical, epidemiologic, surgical and laboratory parameters in evaluating prognosis]

Sixteen patients with jaundice after heart surgery with extracorporeal circulation, were studied. They were divided in 2 groups, according to the postoperative outcome; either death (group I) or hospital discharge (group II). Clinical, epidemiological, surgical and laboratorial aspects were compared in order to ascertain their role in the outcome. The results were analysed by the Student-t test. The main cause of death was low output syndrome, which occurred in 10 cases (62.5%), 5 of them died (31%). A statistically significant difference was observed in the postoperative values of serum GOT (p less than 0.01), GPT (p less than 0.01) and total bilirubin (p less than 0.01), which were then considered prognostic indicators in these patients.

[Intrahepatic and subcapsular hematoma of the liver after hepatic biopsy under laparoscopy. Contribution of ultrasonography]

Over the last few years, ultrasound became important in characterization of space -occupying solid lesions of the liver. Recently, Canadian authors using this method, described a 23% incidence of intrahepatic or subcapsular hematoma after liver biopsy. We prospectively evaluated the incidence of this complication after liver biopsy under laparoscopic guidance in 8 cirrhotic patients, 7 with steatosis, 7 chronic active hepatitis and 4 with intrahepatic cholestasis. Biopsy was performed under general anesthesia provided that prothrombin activity was over 50%, serum fibrinogen was over 100% and platelets over 50.000/mm3. In none of 26 consecutive patients, was an intrahepatic or subcapsular hematoma observed.