Is low-protein diet a possible risk factor of malnutrition in chronic kidney disease patients?

Chronic kidney disease (CKD) is becoming increasingly widespread in the world. Slowing its progression means to prevent uremic complications and improve quality of life of patients. Currently, a low-protein diet (LPD) is one of the tools most used in renal conservative therapy but a possible risk connected to LPD is protein-energy wasting. The aim of this study is evaluate the possible correlation between LPD and malnutrition onset. We enrolled 41 CKD patients, stages IIIb/IV according to K-DIGO guidelines, who followed for 6 weeks a diet with controlled protein intake (recommended dietary allowance 0.7 g per kilogram Ideal Body Weight per day of protein). Our patients showed a significant decrease of serum albumin values after 6 weeks of LDP (T2) compared with baseline values (T0) (P=0.039), whereas C-reactive protein increased significantly (T0 versus T2; P=0.131). From body composition analysis, a significant impairment of fat-free mass percentage at the end of the study was demonstrated (T0 versus T2; P=0.0489), probably related to total body water increase. The muscular mass, body cell mass and body cell mass index are significantly decreased after 6 weeks of LDP (T2). The phase angle is significantly reduced at the end of the study compared with basal values (T0 versus T2; P=0.0001, and T1 versus T2; P=0.0015). This study indicated that LPD slows down the progression of kidney disease but worsens patients' nutritional state.

Regulatory T cells in the immunodiagnosis and outcome of kidney allograft rejection.

Acute rejection (AR) is responsible for up to 12% of graft loss with the highest risk generally occurring during the first six months after transplantation. AR may be broadly classified into humoral as well as cellular rejection. Cellular rejection develops when donor alloantigens, presented by antigen-presenting cells (APCs) through class I or class II HLA molecules, activate the immune response against the allograft, resulting in activation of naive T cells that differentiate into subsets including cytotoxic CD8(+) and helper CD4(+) T cells type 1 (TH1) and TH2 cells or into cytoprotective immunoregulatory T cells (Tregs). The immune reaction directed against a renal allograft has been suggested to be characterized by two major components: a destructive one, mediated by CD4(+) helper and CD8(+) cytotoxic T cells, and a protective response, mediated by Tregs. The balance between these two opposite immune responses can significantly affect the graft survival. Many studies have been performed in order to define the role of Tregs either in the immunodiagnosis of transplant rejection or as predictor of the clinical outcome. However, information available from the literature shows a contradictory picture that deserves further investigation.

Feasibility and safety of granulocytapheresis in Crohn's disease: a prospective cohort study.

BACKGROUND AND OBJECTIVE: This study evaluated the feasibility and safety of granulocytapheresis (GCAP) in inducing and maintaining remission in refractory Crohn's disease. The relationship between the clinical outcomes and the location (ileal or ileocolonic) of disease was also assessed. PATIENTS: We evaluated 16 patients with ileal location (group A), 14 with ileocolonic location (group B). The patients underwent five sessions (1 session/wk) of GCAP (Adacolumn(TM)). CDAI was measured at the end of the GCAP, at 6, 9 and 12 months. RESULTS AND CONCLUSIONS: No major complications were observed. At the end of GCAP, 19 (63.3%) patients showed a clinical remission: 10 (62.5%) in group A versus 9 (64.2%) in group B. At 6 months, 16 (53.3%) of the cases had maintained remission: 9 (56.2%) in group A versus 7 (50.0%) in group B. At 9 months, 13 (43.3%) patients had maintained remission: 7 (43.7%) in group A versus 6 (42.8%) in group B. At 12 months, 12 (40%) patients were still in clinical remission: 7 (43.7%) in group A versus 5 (35.7%) in group B. Risk of relapse was not related to disease location. The procedure was well tolerated and feasible in an important percentage of Crohn's disease patients.

Long-term anti-TNF-alpha treatments reverse the endothelial dysfunction in rheumatoid arthritis: the biological coherence between synovial and endothelial inflammation.

Rheumatoid arthritis (RA) is associated with an excess cardiovascular morbidity and mortality, related to systemic inflammation with endothelial dysfunction (ED) and impaired flow-mediated vasodilation (FMD). We assessed the FMD response to anti-TNF-alpha treatments in 28 RA patients, aged 49.8+/-15.3 years: an unpaired FMD was found in 66.7 percent of our cases and was restored after 6 weeks of anti-TNF-á treatment (13.5+/-5.3 percent vs 4.6+/-4.1 percent, p less than 0.05). Twenty-five percent of the infliximab patients demonstrated a long term response, compared with 60 percent of etanercept and 100 percent of adalimumab patients, after 2 years (p less than 0.01). Infections (3 cases), myocardial ischemia (1 case) or loss of response (4 cases) were associated with a worsened FMD, restored by shifting to adalimumab. The present study confirms that ED is an RA systemic disease marker, responsive to anti-TNF-alpha treatment and sensitive to clinical events or to a loss of response, underlying the biological coherence between synovial and endothelial inflammation.

Rapid identification and antimicrobial susceptibility profiling of Gram-positive cocci in blood cultures with the Vitek 2 system.

Rapid identification and antimicrobial susceptibility profiling of the bacteria in blood cultures can result in clinical and financial benefits. Addition of saponin to the fluid from blood culture bottles promotes the recovery of the bacteria and thus may shorten the turnaround time of the microbiological analyses. In this study we compared the identification and susceptibility profiles of saponin-treated and untreated (standard method) blood cultures monomicrobial for Gram-positive cocci using Vitek 2. We concordantly identified 49 (89%) of 55 monobacterial cultures using the results with the standard method as reference. Complete categorical agreement between the susceptibility profiles with the new and the standard method was found for 26 (53%) of 49 isolates, while discrepancies were seen for 23 (47%) cultures. E-tests indicated that the new method resulted in a correct susceptibility profile for 8 (35%) of these 23 blood cultures. Therefore, 34 (69%) of 49 cultures showed a concordant/correct susceptibility profile for all antimicrobials with an overall error rate of 2.3%. Thus, addition of saponin to the fluid from blood culture bottles of the Bactec 9240 leads to the rapid (results available >or=12 hours earlier) and reliable identification and susceptibility profiling of Gram-positive cocci in blood cultures with Vitek 2.

Duration of remission and long-term prognosis according to the extent of disease in patients with ulcerative colitis on continuous mesalamine treatment.

AIMS: To describe the long-term prognosis of ulcerative colitis (UC) and to establish whether a correlation exists between the different anatomic locations of the disease and the risk of relapse in a homogeneous cohort of patients with UC in clinical remission, all treated with fixed doses of oral mesalamine from the date of enrollment to the appearance of the first relapse. METHOD: We distinguished the patients with pancolitis and left-sided colitis from those with distal colitis. The follow-up lasted up to 5 and 6 years for the patients with pancolitis and left-sided colitis, respectively, and up to 9 years for the patients with distal colitis. RESULTS: One hundred and fifty patients satisfied the enrollment criteria. We registered 19 drop-outs. All the patients had relapsed within 9 years. In most cases relapses arose within 2-3 years. The patients with pancolitis had a shorter time to relapse (100% relapsed after 5 years) than the patients with left-sided colitis (100% after 6 years) or distal colitis (100% after 9 years). None of the enrolled patients developed a cancer. Extraintestinal complications were observed in 9% of cases and surgery was needed in five patients only. CONCLUSION: The first 2-3 years after the enrollment of patients with UC in remission was the period at higher risk of relapse. No relationship was found between the different anatomic locations of the disease and the risk of relapse, even if distal colitis showed a slightly better course.

Treatment of patients with acute ulcerative colitis: conventional corticosteroid therapy (MP) versus granulocytapheresis (GMA): a pilot study.

AIM: The aim of our pilot study is to report the efficacy of granulocytapheresis in patients with acute ulcerative colitis with respect to the use of conventional corticosteroids such as methylprednisolone. METHODS: The activity of disease was evaluated by clinical activity index and endoscopic index. Forty patients with acute ulcerative colitis were randomly divided in two groups of 20 subjects each: one group was treated with five sessions of granulocytapheresis, the other one with methylprednisolone for 5 weeks. Complete response was defined as clinical activity index lower than 6 and endoscopic index lower than 4 after 6 weeks of follow-up. Partial response was defined as clinical activity index lower than 6 but endoscopic index more than 4 after 6 weeks of follow-up. All the conditions not included are classified as nonresponders. RESULTS: All the patients completed the trial. Complete clinical response was observed in 70% of patients treated with granulocytapheresis versus 60% of patients treated with methylprednisolone. A partial response was observed in 20% of patients treated with granulocytapheresis versus 15% of patients treated with methylprednisolone. During the sessions of granulocytapheresis only a transient mild headache was recorded in 10% of patients, while side effects were more common (50%) in the patients treated with methylprednisolone. CONCLUSION: Granulocytapheresis represents a new and promising approach to active ulcerative colitis. In fact, even if more expensive than conventional corticosteroids, it seems slightly more effective and, above all, with side effects much less frequent and serious. Thus, granulocytapheresis cycles could be prolonged or repeated, if necessary, in more severe diseases without significant risks for the patients.

Clinical relevance of colonic lesions in cirrhotic patients with portal hypertension.

BACKGROUND AND STUDY AIMS: This prospective study was conducted in order to evaluate whether the colonic lesions previously described in cirrhotic patients may be of clinical relevance. PATIENTS AND METHODS: Eighty-five patients with cirrhosis of the liver, but without colonic or systemic diseases unrelated to the liver disease, underwent colonoscopy and were followed up for at least 2 years. RESULTS: Colonic varices were observed in 31 % of the patients, portal hypertensive colopathy (PHC; defined as diffuse hyperemia, edema, spider angiomas, and spontaneous bleeding of the colonic mucosa) in 54 %, and normal colonic findings in 18 %. Colonic varices and PHC were present simultaneously in 27 % of the patients. Previous sclerotherapy or band ligation treatment for esophageal varices had been carried out in 27 % and 23 % of the patients, respectively. Portal hypertensive gastropathy was observed in 42 % of the patients. Polyps were found in 12 % of the cirrhotic patients and cancer in 3 %. All of the patients were followed up for at least 2 years; 34 % of them developed upper gastrointestinal hemorrhage (81 % from esophageal varices, 19 % from the stomach), while only 6 % developed lower gastrointestinal bleeding. CONCLUSIONS: Colonic lesions are frequent in cirrhotic patients, but statistical analysis showed that these lesions are not specific for the disease and do not correlate with the etiology and degree of cirrhosis, with the endoscopic treatment of esophageal varices, or with the risk of bleeding from the lower gastrointestinal tract.

Multidetector CT and virtual endoscopy in the evaluation of the esophagus.

In this prospective study, we assessed the diagnostic capabilities of multidetector computed tomography (CT) in various esophageal pathologic conditions. Thirty-three patients underwent a multidetector CT study after esophageal distention by means of effervescent powder administered after induction of pharmacologic esophageal hypotonia. All acquired images were post-processed with two- and three-dimensional software tools. The CT data were compared with the results of conventional radiology (33), endoscopy (28), endoscopy ultrasonography (14), or surgery (14). Follow-up ranged between 4 and 15 months. Esophageal distention in the upper and middle thirds was classified as "good" in 32 of 33 cases (97%); in the lower third, esophageal distention was "good" in 21 of 33 cases (64%). Final diagnoses were leiomyoma (six cases), squamous cell carcinoma (six), adenocarcinoma (four), esophageal infiltration by thyroid cancer (two), benign polyposis (two), chronic esophagitis (five), post-sclerotherapy stenosis (one), no abnormalities (seven). When good distention was achieved, the thickness of unaffected esophageal wall was less than 3 mm (range, 1.5-2.4 mm; mean, 1.9 mm). Pathologic wall thickening was observed in 25 of 33 cases (76%), with values ranging between 3.6 and 36 mm (mean, 9.6 mm). Spiral CT demonstrated 21 true positive cases, and seven true negative cases. There were four false negative cases and one false positive case. Sensitivity was 84%, specificity was 87%, diagnostic accuracy was 85%, positive predictive value was 95%, and negative predictive value was 64%. Evaluation of the esophagus with multidetector CT is a promising technique and easy to use, allowing panoramic exploration, virtual endoluminal visualization, accurate longitudinal and axial evaluations, and simultaneous evaluation of T and N parameters.

Laparoscopic left hemicolectomy in a patient with cirrhosis scheduled for liver transplantation.

Hepatic cirrhosis is a negative prognostic factor for major abdominal surgery, with a greater risk of bleeding, infection, and ascites. The case of a 54-year-man with adenocarcinoma of the sigma affected by hepatitis B virus and hepatitis C virus hepatopathy as well as micro- and macrconodular cirrhosis (Child's B7 stage) waiting for liver transplantation is reported. After a consultation with the liver transplantation our hospital, and considering the the patient's age laparoscopy was determined to be the procedure of choice because it would give him the possibility of a transplantation in the future. A typical left hemicolectomy with left flexure mobilization and mechanic colorectal T-T-anastomosis was therefore performed. All surgical maneuvers in the right hypochondrium were avoided. Mobilization was performed using an ultrasonic scalpel to reduce the risk of bleeding, and the anatomic stump was pulled out by means of a midline minilaparotomy, sparing the anastomotic circles of the abdominal wall. Follow-up evaluation was uneventful. At an 8-month follow-up visit, the patient was in good general condition. In this case, laparoscopic surgery allowed an oncologically suitable colonic resection without complication and poor surgical stress. Moreover, open surgery would have reduced the possibility of a transplantation in the future.

The ambulatory monitoring documents a more elevated blood pressure regimen (pre-hypertension) in normotensives with endothelial dysfunction.

PURPOSE: The present study investigates the blood pressure (BP) 24-h values in normotensives with and without endothelial dysfunction (ED). The scope is to detect differences in BP regimen supporting the hypothesis that the ED is associated with vasopressant effects that can cause a condition of "pre-hypertension". MATERIALS AND METHODS: Thirty-eight normotensives were investigated in their endothelial function by mean of the non-invasive post-ischemic brachial artery vasodilation test (endothelium-dependent vasomotricity). Their were also automatically and non-invasively monitored in their systolic (S) and diastolic (D) BP over the 24-h period in order to confirm that they were not hypertensive. RESULTS: Eight of the investigated normotensives were found to show an ED. A significantly higher daily mean level as well as a more prominent nychtohemeral variability in SBP and DBP 24-h values were observed in the normotensives with ED as compared to the normotensives without ED. The higher BP regimen in the normotensives with ED was found to maintain a circadian rhythm. However, a significant amplification the second harmonic component, with a 12-h period, was observed. The different structure of the BP 24-h pattern in the normotensives with ED was confirmed by the detection of additional ultradian components at the linear-in-period spectral analysis. CONCLUSIONS: The present study documented a significant elevation of BP 24-h values in normotensives with ED that is the reflex of consistent changes in the frequency organization of the BP circadian pattern. The elevation of BP regimen suggests that the ED is associated with vasopressant effects even in normotensives. Such a condition of higher BP in normotensives with ED can be regarded as a status of "pre-hypertension".

Long-term maintenance treatment in ulcerative colitis: a 10-year follow-up.

BACKGROUND: With the extensive use of mesalamine, the natural history of ulcerative colitis is probably changed. AIM: To evaluate the relapse rate and the duration of remission in patients with ulcerative colitis on maintenance treatment with mesalamine. PATIENTS AND METHODS: Enrolled in the study were 95 patients divided into 4 groups according to macroscopic location of the disease and treated with the same therapy starting from the date of enrolment. Patients in all 4 groups were followed-up until relapse occurred. The disease activity was evaluated by the Clinical Activity Index and Endoscopic Index. Patients suitable for recruitment showed a Clinical Activity Index and Endoscopic Index lower than 6 and 4, respectively. The patients with ulcerative pancolitis or left-sided colitis were treated with 1.6 g/day while the cases with proctosigmoiditis or proctitis were treated with 5-acetylsalicylic acid enemas 4 g/day Each patient was evaluated with clinical and endoscopic assessment at a 6-month interval. Relapse was defined as an increase in Clinical Activity Index and Endoscopic Index, of more than 6 and 4, respectively. RESULTS: Five patients dropped-out. All enrolled patients showed a clinical and/or endoscopic relapse within 10 years, the majority 2 or 3 years after diagnosis: pancolitis and left-sided colitis within 2-3 years and patients with distal colitis within 9-10 years. CONCLUSIONS: A relapse was observed in most cases within 3 years, and in all recruited patients within a space of ten years. The extent of the disease in the colon is an important prognostic factor, as patients with distal colitis showed a lesser tendency to relapse.

Higher blood pressure load (baric impact) in normotensives with endothelial dysfunction: a paraphysiological status of "pre-hypertension".

PURPOSE: The present study investigated the blood pressure (BP) load (L), namely Baric Impact (BI), in normotensives with and without endothelial dysfunction (ED). The aim was to detect baric differences supporting the thesis that the ED is associated with vasopressant effects that are responsible for a paraphysiological condition of higher BP (pre-hypertension) even in normotensives. MATERIALS AND METHODS: Thirty-eight normotensives were investigated in their endothelium-dependent vasomotricity by mean of the non-invasive post-ischemic brachial artery vasodilation test. Additionally, their underwent a non-invasive ambulatory (A) BP monitoring (M) over the 24-h span in order to confirm that they were not hypertensive. The ABPM served also to compute the systolic (S) and diastolic (D) BI. RESULTS: The ED was detected in eight normotensives of the investigated group. These cases with ED were found to show a significantly higher SBI and DBI as compared to the normotensives without ED. CONCLUSIONS: The significant elevation of the SBI and DBI in normotensives with ED is an evidence convincing that a dysfunctional endothelium is responsible for vasopressant effects that cause a paraphysiological status of "pre-hypertension".

Decreased sympathetic inhibition in gastroesophageal reflux disease.

This study was undertaken to evaluate autonomic nervous system function in patients with gastroesophageal reflux disease. Based on clinical criteria, 28 consecutive patients with no history of heart, metabolic, or neurologic disease (mean age 41 y, range 20-62 y) reporting with upper gastrointestinal symptoms typical of gastroesophageal reflux underwent esophageal manometry, ambulatory 24-hour pH study with electrocardiographic monitoring, power spectral analysis of heart rate variability, and cardiovascular tests. Twelve healthy subjects served as controls. A positive result of prolonged esophageal pH study (pH in the distal esophagus less than 4, lasting more than 4.2% of recording time) was observed in 21 patients (reflux group); seven patients were categorized in the nonreflux group. No patient showed arrhythmias or any correlation between heart rate variability changes during electrocardiographic monitoring and episodes of reflux (pH less than 4, lasting more than 5 minutes). A decrease of sympathetic function occurred only in the reflux group (p <0.05) supported by the lower increase of systolic/diastolic blood pressure at sustained handgrip. No other cardiovascular tests showed statistically significant differences in the control or nonreflux groups. Total time reflux showed an inverse correlation with sympathetic function in the reflux group (r = -0.415, p <0.028). We concluded that there is some evidence for a slightly decreased sympathetic function in patients with gastroesophageal reflux disease that is inversely correlated with total time reflux. In these patients, decreased sympathetic function may cause dysfunction of intrinsic inhibitory control with increased transient spontaneous lower-esophageal sphincter relaxations, thus resulting in gastroesophageal reflux disease.

Does the initial location of Crohn's disease have an influence on the time-to-relapse in patients under maintenance treatment with oral mesalamine?

The aim of this study was to determine the possible influence of the initial location of Crohn's disease (CD) on the time-to-relapse in patients with quiescent CD treated only with oral mesalamine (5-ASA). We divided 74 consecutive patients in clinical remission into three groups according to the initial location of CD. Group A consisted of 30 cases with an ileal location; group B, 18 with ileocolonic location; and group C, 26 with a colonic location. The patients entered the study if they were in clinical and endoscopic remission for at least 3 months. Relapse was defined by CD Activity Index > or = 150, CD Endoscopic Index of Severity > or =4, and by an abnormal increase of C-reactive protein, white blood cell count, and erythrocyte sedimentation rate; moreover, if it was confirmed by x-ray and/or endoscopy. Time-to-relapse was defined as the interval between the date of enrollment and the date of relapse. The patients with an ileal location showed a relapse within 5 years, with a time-to-relapse of 1 year in 26% of cases, 2 years in 85%, 3 years in 92%, and 4 years in 96%. The patients with ileocolonic location showed a relapse within 4 years, with time-to-relapse of 1 year in 39% of cases, 2 years in 89%, and 3 years in 94%. The cases with a colonic location showed a relapse within 6 years, with time-to-relapse of 1 year in 33% of cases, 2 years in 71%, 3 years in 79%, and 4 years in 87%. Surgical treatment was necessary in 37% of the cases with an ileal location, in 44% with ileocolonic location, and 17% with a colonic location. In conclusion, even if our data lack a statistical significance, we have found that the initial anatomic involvement is not a valid parameter to predict the relapse risk in a homogeneous group under continuous treatment with oral 5-ASA, although ileocolonic location seems to have a more aggressive course.

Interferon plus ribavirin in chronic hepatitis C non-responders to recombinant alpha-interferon.

The aim of this study was to evaluate the most appropriate therapeutic protocol for patients with chronic hepatitis C not responding to a previous course of recombinant interferon alpha-2b (rIFN). Sixty patients were randomly assigned to two groups of 30 subjects each: group A was treated with double dose of the same type of rIFN (6 MU t.i.w.) plus ribavirin for 6 months; group B was treated with the same rIFN dose and duration as group A, but without ribavirin. An end of treatment complete response (ETCR) was defined as alanine transaminase (ALT) normalization with undetectable serum HCV-RNA at the end of the treatment, while an end of treatment biochemical response (ETBR) as ALT normalization with still detectable viraemia. The two groups were homogeneous. The patients with ETCR or ETBR were than followed-up for at least 1 year. A sustained biochemical response (SBR) was defined as the persistence of normal ALT with still detectable viraemia after a 12-month follow-up, and a sustained complete response (SCR) as the persistence of normal ALT with undetectable viraemia. Side-effects were only observed in patients treated with rIFN plus ribavirin: four cases (13%) discontinued the therapy owing to haemolytic anaemia. Combination therapy induced an ETCR in 11 patients (37%) and an ETBR in six (20%), while a SCR was observed in two subjects (7%) and a SBR in four (13%). The use of a double dose of rIFN alone obtained an ETCR in four cases (13%) and an ETBR in five (17%), with a SCR in two (7%) and a SBR in three (10%). Hence, both combination therapy and single treatment with higher rIFN doses were unable to show statistically significant long-term benefits in patients with chronic hepatitis C resistant to a previous course of rIFN treatment.

High-dose interferon plus ribavirin in chronic hepatitis C not responding to recombinant alpha-interferon.

BACKGROUND: Recently, the combination treatment of recombinant alpha-interferon plus ribavirin has been proposed for chronic hepatitis C patients unresponsive to previous therapy with recombinant alpha-interferon alone. AIM: To determine the effectiveness of the combination therapy for the re-treatment of chronic hepatitis C patients unresponsive to previous interferon therapy. Immediate and long-term follow-up data are reported. PATIENTS AND METHODS: A series of 100 patients with chronic hepatitis C not responding to recombinant alpha-interferon 3 MU tiw, were randomly assigned to two groups of 50 patients each: Group A, treated with recombinant alpha-interferon therapy for an additional six months but at a double dosage (6 MU tiw) in association with ribavirin. Group B, same treatment as group A but without ribavirin. All patients responsive to therapy were then followed-up for at least 12 months. At the end of the treatment and at the end of the follow-up period, we distinguished between complete responses (return to normal of alanine aminotransferase with undetectable serum HCV-RNA] and biochemical responses (return to normal of alanine aminotransferase still with detectable viraemia). RESULTS: Side-effects were observed only in patients treated with recombinant alpha-interferon plus ribavirin: 12% discontinued the therapy due to haemolytic anaemia. In group A, the percentages of end-of-treatment complete response, end-of-treatment biochemical response, sustained complete response, and sustained biochemical response, were 38%, 20%, 8%, and 14%, respectively, whilst in group B, these percentages were 12%, 16%, 6%, and 16%, respectively. CONCLUSION: The results indicate that in patients with chronic hepatitis C unresponsive to previous recombinant alpha-interferon therapy, re-treatment with higher recombinant alpha-interferon doses, either alone or in combination with ribavirin, lead to mild long-term benefit. However, the satisfactory end of treatment complete response in group A suggests that a significant percentage of patients are sensitive to the combination therapy; and that a more aggressive therapeutic protocol in this selected subset of patients could result in a larger number of long-lasting responses leading, in turn, to a more favourable cost-effect ratio.

Laser treatment of feeder vessels in subfoveal choroidal neovascular membranes: a revisitation using dynamic indocyanine green angiography.

OBJECTIVE: This study aimed to determine whether the indocyanine green angiography (ICGA)-guided laser treatment of feeder vessels (FVs) may be useful in the management of the subfoveal choroidal neovascular membranes (CNVM) in patients with age-related macular degeneration (ARMD). DESIGN: Noncomparative case series. PARTICIPANTS: The authors considered a series of 15 patients with subfoveal CNVM in whom feeder vessels could be clearly detected by means of dynamic ICGA but not necessarily with fluorescein angiography (FA). On the basis of the indications of the pilot study, the authors also studied a second series of 16 patients with FVs smaller than 85 microm. INTERVENTION: Treatment of FV using argon green laser was performed. The ICGA was performed immediately after treatment, after 2, 7, 30 days, and then every 3 months, to assess FV closure. If an FV appeared to be still patent, it was immediately retreated and the follow-up was started again. The follow-up time ranged from 23 to 34 months for the pilot study and from 4 to 12 months for the second series. MAIN OUTCOME MEASURES: The obliteration of the membrane and change in visual acuity from baseline were measured. The effect on the treatment of the number and width of the FVs, and the size and location of the membrane, also was evaluated. RESULTS: In the pilot study, the CNVM was obliterated after the first treatment in only one patient, five patients needed more than one treatment, and obliteration failed in nine patients (40% success rate). The rate of success was affected by the width and number of the FVs. The success rate in the second series of 16 patients was higher (75%). CONCLUSIONS: The success of the laser treatment of FVs depends on their width, length, and number. Dynamic ICGA, which detects smaller FVs and makes it possible to control the laser effect and initiate immediate retreatment in the case of incomplete FV closure, should be considered mandatory for this type of treatment; a comparable success rate would have been unlikely using the other currently available methods of treating subfoveal CNVMs.

[Eosinophilic gastroenteritis. A report of a clinical case]. / Gastroenterite da eosinofili. Descrizione di un caso clinico.

Eosinophilic gastroenteritis is an inflammatory pathology with an unknown etiology characterised by the presence of an eosinophil infiltrate on the intestinal wall. The symptoms (bleeding, occlusion, fistulae, etc.) may lead to surgery even if the best treatment is medical. Endoscopic examination with specific multiple biopsies is indispensable for the diagnosis of the pathology. The authors report the case of a 2-month-old baby suffering from intermittent pyloric obstruction secondary to eosinophilic gastroenteritis which was wrongly interpreted as hypertrophic stenosis of the pylorus.

Colonic disease in cirrhotic patients with portal hypertension: an endoscopic and clinical evaluation.

Fifty cirrhotic patients with portal hypertension but without colonic or systemic disease underwent lower gastrointestinal endoscopy in order to investigate the effects, if any, of portal hypertension on the colon. Fifty patients without liver or systemic disease, examined by colonoscopy because of irritable bowel syndrome in the same period served as controls. Rectosigmoid varices were observed in 34% of the cirrhotic patients and 2% of the controls. Hemorrhoids were observed in 70% of the cirrhotic patients and 48% of the controls. Multiple vascular-appearing lesions were found in 16% of the cirrhotic patients and 6% of the controls. Nonspecific inflammatory changes were noted in 10% of the cirrhotic patients and 4% of the controls. Simultaneous presence, in the same patient, of rectosigmoid varices, hemorrhoids, multiple vascular-appearing lesions, and nonspecific inflammatory changes, was observed in only five (10%) of the cirrhotic patients. We found polyps in 12% of the cirrhotic patients and 14% of the controls, and a malignant tumor in 4% of the cirrhotic patients. The patients with normal colonoscopic findings were 8% of the cirrhotic patients and 36% of the controls. All patients and controls were followed up for 1 year; there was no gastrointestinal hemorrhage among controls, whereas 34% of the cirrhotic patients had an upper gastrointestinal hemorrhage (88% from esophageal varices, 12% from the stomach) and 4% had a lower gastrointestinal hemorrhage (one from rectosigmoid varices and one from nonspecific inflammatory lesions). Colonic lesions were significantly more frequent in the cirrhotic patients (92%) than in the control group (64%); however, such lesions did not seem specific to the disease and were not statistically correlated with the degree of esophageal varices by Child's grading, the etiology of cirrhosis, or the bleeding risk from the lower gastrointestinal tract.