Evaluación de ingesta en pacientes con hepatopatías crónicas / Evaluation of ingestion in patients with chronic liver diseases

La malnutrición calórico-protéica (MCP) es frecuente entre los pacientes con hepatopatías crónicas (HC) estableciéndose hasta en un 80 por ciento. El problema es multifactorial, siendo la disminución de la ingesta una de las causas más relevantes. Objetivo: evaluar la ingesta calórico-protéica en pacientes con HC. Se evaluaron prospectivamente 60 pacientes (26 mujeres, 43,3 por ciento) con una edad media de 54,1 años, con los siguientes diagnósticos: cirrosis biliar primaria 11 (18,3 por ciento), cirrosis alcohólica 26 (46,3 por ciento), hepatopatías autoinmunes 12 (20 por ciento), cirrosis criptogenética 6 (10 por ciento), Budd-Chiari 1 (1,7 por ciento), Hemocromatosis 1 (1,7 por ciento), cirrosis viral 3 (5 por ciento). Se utilizó el recordatorio de 3 días para la recolección de datos de ingesta, la evaluación global subjetiva EGS) para evaluación nutricional y la clasificación de Child-Pugh para evaluar severidad de la hepatopatía...

High-dose melphalan with autologous hematopoietic stem cell transplantation for acute myeloid leukemia: results of a retrospective analysis of the Italian Pediatric Group for Bone Marrow Transplantation.

This retrospective study from the Italian Association of Pediatric Hematology Oncology-Bone Marrow Transplant Group (AIEOP-TMO) reports the results of consolidation with high-dose melphalan and autologous hematopoietic stem cell transplantation (auto-HSCT) in patients with acute myeloid leukemia (AML) in first complete remission (CR1). From October 1994 to July 1999, 20 patients (median age 9.9 years, range 0.11-16.2) were treated in six centers. Eighteen had de novo AML and two had secondary AML. According to BFM criteria, 10 were classified as standard- and 10 as high-risk patients, respectively. The median time from diagnosis to CR1 and from diagnosis to Auto-HSCT were 1.1 months (range 0.8-1.6) and 4.3 months (range 3.1-6.2), respectively. Purging with either mafosfamide (three) or in vivo interleukin-2 (four) was performed in seven of 20 patients. Melphalan was administered at a dosage of 150-220 mg/m(2) (median 180). Median total number of nucleated cells infused was 2.5 x 10(8)/kg (range 1.1-8.9). The myeloablative regimen was well tolerated with no toxic death, veno-occlusive disease or life-threatening complications. All patients had hematopoietic recovery in a median time of 27 days for neutrophils and 44 days for platelets. Eight of 20 patients relapsed after a median time of 7.2 months from transplant (range 5.7-15.9). Six of them died (five of progression of disease and one of sepsis) while the remaining two patients are alive in CR2. The 3-year cumulative probability of survival and event-free-survival (EFS) is 62% and 56%, respectively. This study showed that in pediatric patients with AML consolidation of CR1 with high-dose melphalan allows survival and EFS to be obtained comparable to other auto-HSCT or chemotherapy published series with a potential sparing effect both on duration of treatment (with respect to chemotherapy) and on long-term side-effects (with respect to auto-HSCT with TBI or busulfan containing regimens).

Shoulder arthroplasty. Indications, contraindications and complications.

Prosthetic substitution of the glenohumeral joint, begun at the end of the last century, has developed greatly in recent years. Today the most widely used shoulder prostheses are defined as "modular" because of their extensive adaptability. The capacity to adapt to anatomic variations must be incorporated within their structure, and normal articular biomechanics must be respected. The choice of prosthesis must be based on the condition of the joint surfaces, on the anatomic and functional condition of the rotator cuff. So endoprosthesis of the shoulder is indicated for avascular necrosis of the head of the humerus, fractures and pseudoarthrosis of the extreme proximal end of the humerus, arthropathy following rotator cuff rupture. Total shoulder prosthetization is indicated for glenohumeral osteoarthritis, rheumatoid arthritis and outcomes of endoprosthesis. The principal contraindications for shoulder replacement include an infection in progress, Charcot's arthropathy and severe neurological pathologies. The complications of shoulder prostheses include infection, dislocation, loosening of a component, periprosthetic humeral and glenoid fractures, nerve injuries, fractures of a prosthetic component and ectopic ossification. At present prosthetic substitution of the glenohumeral joint offers good results. Indispensable conditions for these results include anatomic and functional integrity of the musculature, good bone quality, correct positioning of the prosthetic components and a proper rehabilitation program.

Italian guidelines for the management of infectious complications in pediatric oncology: empirical antimicrobial therapy of febrile neutropenia.

The Italian Association for Paediatric Haematology and Oncology prepared a guideline document aimed at unifying and rationalising as much as possible the management of febrile neutropenia in children with cancer, because of the potential impact of these procedures on hospital costs and on the development of antibiotic resistance. Before starting anti-infective therapy, at least 2 blood cultures, a throat swab, urine-culture, and cultures from any suspected infected site, should be performed. Routine chest X-rays at onset of febrile neutropenia are probably not necessary, in absence of respiratory signs. At the present time, the safer option probably remains the combination of a beta-lactam and an aminoglycoside, and treating febrile neutropenia outside of hospital should be considered an investigational approach. The choice of the most appropriated regimen for each institution should be based also on the local bacteriological statistics and patterns of bacterial resistance. Antibiotic toxicity and cost should be other important factors. Every subsequent addition or substitution of antibiotics should be based on objective signs of clinical deterioration. The only accepted empirical modification is empirical antifungal therapy, while the empirical addition of a glycopeptide antibiotic cannot be recommended.

Isolated avulsion fracture of the lesser tuberosity of the humerus. Report of two cases.

We describe two cases of isolated avulsion fracture of the lesser tuberosity: this is an extremely rare pathology, and to our knowledge only 34 cases have been reported in the literature. In the present cases, standard radiography and computed tomography clearly evidenced the detached bone fragments. As the patients refused surgical reduction, they were treated conservatively. Outcomes were successful, and three months after injury both of them returned to normal activity with only slight limitation in external rotation. At their check-up six-months after injury the patients continued to carry on normal activity, in both cases their limitation in external rotation had decreased even further. Both patients were pain-free and satisfied with their treatment outcome.

Titanium anchors for the repair of rotator cuff tears: preliminary report of a surgical technique.

We used titanium anchors for the surgical repair of rotator cuff tears in 34 selected patients, all of whom were < 60 years of age, had good bone quality, and had no known metabolic bone diseases. Nine tears were repaired within 6 months, 15 within 6-12 months, and 10 later than 12 months after injury. Tear size was graded as small (10 patients), medium (15 patients), and large (nine patients) during open operation. After 6-24 months of follow-up, 30 patients reported satisfactory pain relief, function, active forward flexion, and muscle strength [18 excellent and 12 good results based on the University of California at Los Angeles rating system (UCLA scores)]; there were no implant failures (p < 0.001). Two patients had unsatisfactory function but good relief of pain, whereas two patients were dissatisfied with their overall result (four poor results based on UCLA scores). Although trans-bone suturing is presently the most common and successful surgical technique for rotator cuff tears, we found that use of titanium anchors shortens operative time and has results comparable with the traditional technique. Titanium anchors should not be used when bone quality is poor or good patient compliance is doubtful. They are also contraindicated, as our four poor results indicate, when the tear is old (> 6 months) and large (diameter > 5 cm with significant tissue degeneration).

Osteonecrosis of the femoral head associated with pregnancy. Report of two cases.

Osteonecrosis of the femoral head developed in two patients, that had taken oral contraceptives for four and eight years respectively, during pregnancy. There were non demonstrable predisposing factors. The symptoms were first noted during the last trimester, and after the delivery improved significantly. Results of examinations, radiography and scanning were consistent with diagnosis of avascular osteonecrosis of the femoral head. The possibility that the long term use of oral contraceptives, might have played a role in the development of femoral head necrosis is stressed by the authors.

[Anesthesia in percutaneous discectomy by the Onik's technique]. / L'anestesia nella discectomia percutanea secondo Onik.

The type of anaesthesia used in percutaneous discectomy, a new technique for treating slipped disc, is described. The personal series consist of 960 patients. In 768, local anaesthesia by infiltration of the anatomical trajectory was used as a follow-up to nucleotome. In the rest, general anaesthesia was used. Conclusion are drawn from the comparison.

Bone scanning in the evaluation of total hip replacement.

The value of 99mTc-MDP bone scan in the early diagnosis of cementless total hip loosening is assessed by means of a review of 26 patients who underwent total hip replacement for arthritis or femoral neck fracture. Bone scan was performed, selecting regions of interest in the proximal diaphyses of both femurs and calculating the ratio of radionuclide uptake. This ratio returned to normal 6-12 months after operation. Bone scan can therefore serve as a point of reference for the prognosis of the implant.

[Evaluation of physiological and pathological activity of osteoclasts and osteoblasts with special reference to calciotropic hormones: parathyroid hormone, calcitonin and calcitriol]. / Valutazione delle attività fisiologiche e patologiche degli osteoclasti e degli osteoblasti con particolare riferimento agli ormoni calciotropi: paratormone, calcitonina e calcitriolo.

After introductory remarks concerning the pathophysiologic activities of osteoclasts and osteoblast, the author considers the three main pathologies: primary hyperparathyroidism, osteomalacia, and Paget's disease. These pathologies represent an excellent model for the pathophysiologic and clinico-therapeutic evaluation of some calciotropic hormones, viz. parathormone, calcitriol, and calcitonin.

[Evaluation of a new non-steroidal anti-inflammatory agent in degenerative osteo-articular pathology]. / Valutazione di un nuovo antiflogistico non steroideo nella patologia degenerativa osteo-articolare.

Cinnoxicam (Sinartrol) was used in 20 patients with inflammatory-degenerative osteoarticular diseases. The new NSAID was administered by oral or rectal route once daily for a standard 15-day period. The treatment brought about a significant improvement in the clinical variables considered (spontaneous pain at rest and on movement and functional limitation), which was observed within a few days of starting therapy. Tolerance was good, only a few slight side-effects having been reported.

Sunspots and hip fractures.

In this paper a remarkable statistical link between sunspot cycles and prevalence of hip fractures in the elderly is shown. Hip fractures in old people are due to: 1. increased bone fragility for metabolic bone disease; 2. increased propension to fall. Though it is obvious that a correlation does not imply any causal relationship, reasonable conjectures can be allowed. The hypothesis of an 11-year cyclic variation of ultraviolet radiation as a cause of hip fractures is untenable; one may better assume that solar flares can negatively influence the nervous postural regulation leading to a greater propensity to accidental falls.

[Additional contribution to the epidemiology of fractures of the proximal end of the femur in the elderly (1965-1985)]. / Ulteriore contributo alla epidemiologia delle fratture dell'estremo prossimale del femore negli anziani (1965-1985).

The seasonal incidence of hip fractures was studied in the Department of Orthopaedics of the University of Siena in a 22 year period (1965-1985). The fracture incidence rate per 100,000 individuals in the population at risk was calculated. The incidence rate of fracture increased significantly in women during the period studied, whereas there was no significant increase in men.

Epidemiology of hip fractures in Siena, Italy, 1975-1985.

A survey of 1567 fractures of the proximal end of the femur due to minor trauma occurring in elderly people was performed. The fracture incidence rate per 100,000 individuals in the population at risk was calculated. Hip fracture prevailed in women with a sex ratio of women to men of 3.81; in both sexes the incidence was more closely related to age than any other factor. The incidence rate of fracture increased significantly in women during the period from 1975 to 1985, whereas there was no significant increase in men during this time. This change may be related to the continuing trend toward a greater proportion of elderly women in the population. The incidence rate in men showed a long-cycle periodic behavior correlated with the long-cycle trend of cloud cover and rainfall; it is possible that precipitation and a greater occurrence of femoral fractures might be interrelated in men. This parallelism was not evident in women. In women the rise in fracture rate was not continuous but decreased periodically. The zeniths of fracture incidence were preceded two years by a decrease in temperature and an increase in cloud cover and rainfall, suggesting a possible relationship between fractures and the diminution of ultraviolet radiation.

Serum osteocalcin radioimmunoassay in bone diseases.

Osteocalcin (or bone Gla protein, BGP) is a non-collagenous vitamin K-dependent protein accounting for 1-2% of the total bone proteins. It represents a specific index of osteoblastic activity and directly reflects the bone turnover. Serum levels of osteocalcin were measured by a radioimmunoassay method. In 40 postmenopausal women with osteoporosis, mean serum BGP levels were lower than the normal range (3.69 +/- 1.35 ng/ml), whereas they significantly increased in 7 patients with osteomalacia (10.48 +/- 3.05 ng/ml), in 12 patients with secondary hyperparathyroidism (11.1 +/- 4.9 ng/ml) and in 41 patients with Paget's disease (12.09 +/- 6.5 ng/ml). Four patients with primary hyperparathyroidism showed very high BGP levels (64.0 +/- 32.3 ng/ml), which strikingly fell after the surgical removal of a parathyroid adenoma. These results confirm that the quantitation of serum osteocalcin is a specific and sensitive method in the diagnosis of bone disease, represents a useful index of bone turnover and is particularly helpful in the follow-up of patients with treated bone disease.

[Osteocalcin]. / La osteocalcina.

Among the vitamin K-dependent proteins, characterized by a high content of gamma-carboxyglutamic acid (Gla), one has been identified in bone tissue which has been referred to as osteocalcin (BGP): it has been found in fish, birds, mammalians, primates and in man without significant changes in structure. "In vitro" and "in vivo" studies in the experimental animal and in man have shown that BGP: 1) binds to hydroxyapatite crystals in bone tissue at the maturation of the mineral phase; 2) is probably synthesized by the osteoblasts; 3) circulates as a newly synthesized molecule before binding to bone; 4) shows a rapid turnover rate and is subjected to renal clearance. In conclusion osteocalcin seems to represent a very good index of osteoblast activity. BGP ca be measured in biological fluids by radioimmunoassay. Plasma levels in man range 4-7 ng/ml, they increase in malignant or metabolic disorders (Paget's disease of bone, bone metastases, hyperparathyroidism) and decrease in hypoparathyroidism. In this paper we report the results obtained using a new radioimmunoassay for osteocalcin; the plasma levels were measured in 72 normal adults aged 18-84 years (37 males, 35 females) and in three normal adolescents. The normal range (M +/- SD) was found to be 4,1-7,84 ng/ml. No significant differences were found between males and females, whereas adolescents showed significantly higher values than adults. A positive correlation was found between plasma BGP level and age of subjects in males as well as in females (r = 0,613, p less than 0,001). Fifteen patients with Paget's disease and two with primary hyperparathyroidism showed very high values which fell dramatically in the latter group after surgical removal of parathyroid adenoma. Six cases of secondary hyperparathyroidism were also found to have higher values than normal. The significance of the progressive increase in BGP with increasing age is still to be interpreted.