Conversion from twice-daily to once-daily Tacrolimus administration in liver transplant patient: results of long term follow-up.

OBJECTIVES: The aim of this study was to assess the long term effects of once-daily tacrolimus (OD-TAC) in a cohort of stable liver recipients converted from the twice daily tacrolimus (TD TAC), with a particular attention on the possible effects on renal function. PATIENTS AND METHODS: Between September 2008 and September 2010 conversion from TD-TAC to OD-TAC was proposed in adult stable liver transplant recipients who were followed as outpatients in our Transplant centre. Conversion from TC-TAC to OD-TAC was based on a 1 mg: 1 mg proportion. Tacrolimus through levels, laboratory parameters, metabolic disorders and any adverse events were evaluated at 1, 3, 6, 12 and 24 months after conversion. Renal function was evaluated using creatinine plasma levels and estimated glomerular filtration rate (GFR) derived from the Modification of Diet in Renal Disease (MDRD). Analysis of variance and t test for paired data were utilised for the comparison of the results obtained at the scheduled controls. RESULTS: Sixty-five patients were enrolled in the study (50 males, 15 females, mean age 59±8 years). Median time since liver transplant (LT) was 39 months (range: 6 to 83 months). All patients were followed for a minimum of 12 months. Ninety per cent of patients stabilized their blood levels within 45 days. Liver function, glucose and plasma lipids concentration and arterial blood pressure remained stable during the study. Renal function improved during the 24 months of follow-up. No adverse events or acute rejection episodes were recorded during the study. CONCLUSIONS: Considering the advantage on patient compliance, the equivalent efficacy and the adequate safety of OD-TAC formulation may represent a useful option in liver transplant patients, with a possible advantage on renal function.

Assessment of the link between atmospheric dispersion and chemical composition of PM10 at 2-h time resolution.

The concentration of air pollutants is governed by both emission rate and atmospheric dispersion conditions. The role played by the atmospheric mixing height in determining the daily time pattern of PM components at the time resolution of 2 h was studied during 21 days of observation selected from a 2-month field campaign carried out in the urban area of Rome, Italy. Natural radioactivity was used to obtain information about the mixing properties of the lower atmosphere throughout the day and allowed the identification of advection and stability periods. PM10 composition was determined by X-ray fluorescence, ion chromatography, inductively coupled plasma-mass spectrometry and thermo-optical analysis. A satisfactory mass closure was obtained on a 2-h basis, and the time pattern of the PM10 macro-sources (soil, sea, secondary inorganics, organics, traffic exhaust) was acquired at the same time scale. After a complete quality control procedure, 27 main components and source tracers were selected for further elaboration. On this database, we identified some groups of co-varying species related to the main sources of PM. Each group showed a peculiar behaviour in relation to the mixing depth. PM components released by soil, biomass burning and traffic exhaust, and, particularly, ammonium nitrate, showed a clear dependence on the mixing properties of the lower atmosphere. Biomass burning components and organics peaked during the night hours (around midnight), following the atmospheric stabilization and increased emission rate. Traffic exhausts and non-exhausts species also peaked in the evening, but they showed a second, minor increase between 6:00 and 10:00 when the strengthening of the emission rate (morning rush hour) was counterbalanced by the dilution of the atmosphere (increasing mixing depth). In the case of ammonium nitrate, high concentrations were kept during the whole night and morning.

Outcome after liver transplantation in patients with cirrhosis and hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is considered an optimal indication for liver transplantation (LT) because it may eliminate both the tumor and the underlying liver disease. The present study sought to compare cumulative survival, rate of HCC recurrence, and causes of death among patients with cirrhosis and HCC before and after the adoption of more restrictive criteria (Milan selection criteria) at the time of patient listing. Among 226 adult patients who received an elective liver transplantation between 1999 and 2005, 58 (27%) had a diagnosis of HCC at the time. The 38 patients who underwent transplantation for HCC in the period 1989 to 1998 were considered the "historical group." After LT (mean follow-up, 34 + 28 months), the cumulative survival rate was better among HCC versus non-HCC recipients (93% vs 71% at 1 year and 81% vs 67% at 3 years, respectively; P < .046), although the difference tended to attenuate after 5 years (66% vs 67%, respectively). Tumor recurrence (evaluated in patients surviving at least 3 months after LT) was observed in 10/31 in the historical group versus 4/53 among those who underwent transplantation after 1999. Among the causes of death, recurrence represented 50% in the old series and 23% in patients who underwent transplantation after 1999. Cumulative survival significantly improved among HCC patients who underwent transplantation after 1999 (93% vs 66% at 1 year and 81% vs 50% at 3 years; P < .00001). The 58 patients who underwent transplantation with a diagnosis of cirrhosis and concomitant HCC after 1999 showed even better survival than patients who underwent transplantation for end-stage liver disease without malignancy.

Surgical second look in ovarian cancer: a randomized study in patients with laparoscopic complete remission--a Northeastern Oncology Cooperative Group-Ovarian Cancer Cooperative Group Study.

PURPOSE: The usefulness of extensive and repetitive surgery for patients with ovarian cancer still remains unproven (at least for some conditions). We planned an accurate prospective test of the hypothesis that patients with advanced-stage disease, after they had reached a clinical complete remission (CR), may benefit from surgical second look (SSL). PATIENTS AND METHODS: One hundred two patients in CR (as assessed by clinical findings, markers, and visualization by computed tomographic [CT] scan and laparoscopy), after initial debulking and first-line chemotherapy, were randomized to two arms, which were well balanced for predictive criteria such as age, stage at presentation, histology, grading, date of randomization, and residua after first surgery. Forty-eight patients were randomly assigned to receive follow-up evaluation only, while 54 were assigned to receive second surgery (eight of them refused). Of 46 surgical patients, 35 had negative and 11 positive surgical findings (24% clinically false-negative). RESULTS: Despite the microscopic residua found at open surgery, and the fact that the patients were then treated with second-line chemotherapy, SSL did not increase the probability of survival in this setting. In an analysis of the results according to the intention-to-treat criteria, after a 60-month follow-up period, the overall survival rates in the two groups of patients (SSL v no SSL) were 65% and 78%, respectively (P = .14). Multivariate analysis according to predictive criteria confirmed there was no significant difference between the two groups (P = .39). CONCLUSION: Our study shows the following: (1) our second-line treatment is scarcely effective; (2) SSL accurately defines complete responders to first-line chemotherapy; (3) SSL per se does not prolong survival; and (4) if confirmed, a less invasive procedure could replace SSL as a valuable method in new first-line regimens in ovarian cancer patients with clinical CR confirmed by laparoscopy.

Improvement of insulin sensitivity by metformin treatment does not lower blood pressure of nonobese insulin-resistant hypertensive patients with normal glucose tolerance.

Nine hypertensive patients with body mass indexes between 24-27 kg/m2 and normal glucose tolerance with at least a postchallenge plasma insulin level greater than 360 pmol/L were recruited for a double blind, cross-over study with metformin (850 mg, twice daily) and placebo. Each treatment lasted 1 month. Before and after each treatment, hormone and substrate concentrations were determined, blood pressure was monitored over 24 h, and insulin sensitivity was measured by a euglycemic (4.7 mmol/L) hyperinsulinemic (450 pmol/L) clamp study. Renal cation excretion and erythrocyte membrane cation heteroexchange were measured. Metformin, compared to placebo, did not affect body weight (70 +/- 7 vs. 70 +/- 7 kg), fasting plasma glucose (4.8 +/- 0.1 vs. 4.8 +/- 0.1 mmol/L), total cholesterol (5.38+/0.33 vs. 5.48 +/- 0.38 mmol/L), or triglycerides (1.73 +/- 0.72 vs. 1.91 0.89 mmol/L). Nevertheless, after metformin treatment, the plasma high density lipoprotein cholesterol concentration increased (1.42 +/- 0.18 vs. 1.34 0.16 mmol/L), and the plasma insulin level dropped (62 +/- 10 vs. 88+/- 12 pmol/L; both P < 0.05). Insulin-mediated glucose disposal was higher after metformin treatment (26.1 +/- 2.4 vs. 19.3 +/- 2.3 micromol/min x kg; P < 0.01), whereas hepatic glucose production was completely suppressed. These positive metformin-induced metabolic effects were not associated with a significant change in mean daily blood pressure levels (141 +/- 6/89 +/- 3 vs. 142 +/- 7/90 +/- 3 mm Hg). Compared to placebo, metformin increased the excretion of sodium, potassium, and lithium by enhancing their glomerular filtration rate. Na+/Li+ countertransport was not affected by metformin. However, the apparent affinity for H+ of Na+/H+ exchange was increased, and the Hill coefficient was decreased. In conclusion, 1 month of metformin administration to patients with essential hypertension and normal glucose tolerance 1) reduces the basal plasma insulin concentration, 2) improves whole body insulin-mediated glucose utilization, and 3) improves plasma high density lipoprotein cholesterol levels. Despite these positive effects, metformin did not reduce arterial blood pressure.

Cisplatin versus carboplatin in combination with mitomycin and vinblastine in advanced non small cell lung cancer. A multicenter, randomized phase III trial.

BACKGROUND: In advanced not selected NSCLC chemotherapy achieved an advantage of approximately 1-2 months on median survival versus best supportive care. Chemotherapy seems to improve symptoms control, even if randomised studies with quality of life as first endpoint are lacking and often chemotherapy toxicity compromises the frail cost/benefit ratio. The aim of the present study is to evaluate the impact on QoL, substituting cisplatin, a pivot drug in NSCLC therapy, with carboplatin, an analogue with an improved toxicity profile. The combination of cisplatin with Mitomycin and Vinblastine was one of the most frequently used in the palliative setting at the time of design of our study. METHODS: Patients were randomized to receive MVP regimen (Mitomycin-C 8 mg/m2 d1, Vinblastine 4 mg/m2 d 1-8, Cisplatin 100 mg/m2 d1) or MVC regimen (Mitomycin-C 8 mg/m2 d1, Vinblastine 4 mg/m2 d 1-8, Carboplatin 300 mg/m2 d1) every 3 weeks. The QoL was evaluated by the Spitzer QL-Index and by the EORTC QLQ-C30+LC 13 questionnaires before chemotherapy, after one cycle, after three cycles, and then every 6 weeks in the first 6 months and every 3 months thenafter. RESULTS: From September 1994 to July 1997, 153 consecutive patients were randomized to MVP (75 patients) or MVC arm (78 patients). Despite difficulties in carrying out and analysing QoL items in such patients, the global QoL evaluated by the Spitzer's questionnaire suggested an advantage for MVC regimen (P=0.05) and a significant difference was observed in global health subdomain (P=0.04). The disease-related symptoms improved with time, and the benefits lasted for the entire treatment period. When evaluated with the EORTC questionnaire there was significantly less nausea and vomiting (P=0.0001), appetite loss (P=0.01), insomnia (P=0.03), constipation (P=0.01) and peripheral neuropathy (P=0.01) in favour of MVC, and a trend for less hair loss (P=0.05). The advantage lasted for all the duration of chemotherapy. No differences were observed in global quality of life subdomain (P=0.40) between the two regimen. QoL was the first endpoint and the statistical power was inadequate to assess other parameters. However, we reported a response rate of 43.1 and 38.6%, respectively, in MVP and MVC arm (P=0.59) and a median survival of 10.2 and 7.2 months, respectively, for cisplatin and carboplatin arm (P=0.39). CONCLUSIONS: The carboplatin containing regimen (MVC) has a significant better toxicity profile than the cisplatin containing (MVP) regimen as proven both by the EORTC questionnaires and by the WHO toxicity data reported by physicians. No significant differences in terms of response rate, time to progression and overall survival were observed between the two regimen. The two chemotherapy regimen showed a similar effectiveness in symptom palliation when evaluated with C30 addendum of EORTC QOL questionnaire. With the Spitzer's questionnaires a trend towards an improved quality of life index was observed during treatment with the carboplatin combination in comparison to the cisplatin combination. This difference, however, was not observed when the global quality of life was evaluated with the EORTC patients compiled questionnaires. A carboplatin containing regimen with better toxicity profile and a similar potentiality for symptoms control offers an option in comparison to similar cisplatin containing combinations in the palliative treatment of advanced NSCLC.

Effects of canrenoate on red cell sodium transport and calf flow in essential hypertension.

The effects of potassium canrenoate (100 mg/day, orally for 1 month) on blood pressure, calf blood flow at rest and after ouabain (0.5 mg intravenous bolus), and red cell Na homeostasis were investigated in 15 patients (7 men, 8 women, aged 18 to 63) with essential hypertension and without peripheral vascular diseases. On placebo, acute intravenous ouabain administration significantly and transiently reduced calf flow and increased calf vascular resistance without affecting blood pressure. Canrenoate significantly decreased blood pressure (from 159 +/- 21/105 +/- 9 mm Hg to 141 +/- 14/94 +/- 10, P < .05) and the rise of calf resistance after intravenous ouabain bolus. The latter effect was variable, since it was inhibited almost completely in 8 patients and unaffected in the others. In the patients in whom exogenously administered ouabain was antagonized, canrenoate diminished blood pressure through vasodilation and heightened the red cell Na/K pump. None of these parameters changed significantly in the other patients. Thus these data suggest that the fall in vascular resistance induced by canrenoate is mediated, in part, by the antagonism of endogenous ouabain-like factors.

Gastric non-Hodgkin's lymphoma: analysis of 252 patients from a multicenter study.

AIMS AND BACKGROUND: The stomach is the most common site of primary extranodal non-Hodgkin's lymphoma (NHL) and no agreement has been reached so far on the best therapeutic approach. The main objects of this study were to report the long-term results and to evaluate the importance of some possible prognostic factors in a large series of patients. NHL was considered primary gastric if the main symptoms at presentation were those of gastric disease. METHODS AND STUDY DESIGN: We analyzed 252 consecutive patients treated between 1980 and 1993 in five hospitals in north-east Italy. According to the Working Formulation, 98 patients had low grade lymphoma, 59 intermediate grade (D to F), 81 G or high grade and 14 were not classified. The patients were divided into two groups: one including patients with limited disease (localized to the stomach or perigastric lymph nodes: 165 patients) and one including those with advanced disease (87 patients). The treatment consisted of surgery, chemotherapy, radiotherapy or combinations of these. Sixteen patients received only supportive therapy. RESULTS: The five-year overall survival was 65.4%: 80.3% for patients with limited disease and 36.7% for those with advanced disease (P < 0.0001). Among the limited disease patients the five-year survival was 84.4% for those treated with gastrectomy alone and 88.7% for those who received also adjuvant chemotherapy (P = 0.11). However, while chemotherapy did not improve survival in low grade NHL, it seemed to produce a better survival in the intermediate and high grade groups (P = 0.06). Twelve patients were treated with primary chemotherapy and the five-year survival was 71.2%. In multivariate regression analysis the most important variable for overall survival was surgery for the whole group of 252 patients (P < 0.0001), while it was age for the group with limited disease (P = 0.0008). CONCLUSIONS: Surgery alone can be curative for most patients with gastric lymphoma limited to the stomach or to the perigastric lymph nodes; surgery followed by chemotherapy seems to produce better results than surgery alone in intermediate and high grade lymphomas. Also a non-surgical approach with first-line chemotherapy is associated with a high rate of complete remissions and five-year survival. In advanced disease the five-year survival is similar to that of nodal NHL.

[The emotive and cognitive reactions in temporary pharmacological menopause]. / Reazioni emotivo-cognitive in menopausa farmacologica temporanea.

The authors have attempted to evaluate the extent to which menopausal crisis is linked to hypoestrogenism and the extent to which it is linked to the socioenvironmental context in which it takes place. The study analyses emotional and cognitive aspects in a group of women in temporary menopause which was pharmacologically induced for therapeutic purposes. The study was carried out in 30 patients suffering from benign gynecological pathologies receiving ovarian steroidogenesis-blocking treatment. Treatment consisted of a subcutaneous administration of a Gn-Rh analog every 28 days for 6 months. After having collected information regarding the symptoms that appeared following the administration of therapy, the authors evaluated the emotive (anxiety and depression) and cognitive (short-term memory and concentration) conditions of patients using psychometric reactives performed during the first check-up, and then repeated at the 3rd, 5th and 7th control visit: the State-Trait-Anxiety-Inventory to assess trait anxiety and state anxiety; scale D of the Minnesota Multiphasic Personality Inventory to assess depression; the sub-test for memory of figures from Wechsler-Bellevue Intelligence Scale to evaluate short-term memory; the Toulouse-Pieron reactive to evaluate attention and concentration. The results obtained were analysed statistically using Student's t-test and Pearson's coefficient. An analysis of the data shows that, after the first doses of the drug stress trends to diminish from the high levels recorded at the first visit, stabilising at normal values throughout treatment. Like anxiety and depression, concentration and memory do not show marked variations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pregnancy in HIV positive women: psycho-emotional aspects. Study of 16 cases]. / Gravidanza in donne HIV positive: aspetti psicoemotivi. Studio su sedici casi.

The aim of this study was to analyse the day-to-day life of HIV-positive women during pregnancy and to assess the emotions deriving from their relations with the baby during the first few months of life. The study was carried out on a group of 16 HIV-positive women aged between 19 and 37 years old (mean age 27.3 years) who underwent a guided interview using a questionnaire. The questionnaire, which was mainly based on questions requiring a free answer, focused on four main areas: 1) the woman's reaction to HIV-positive status; 2) the influence of HIV-positive status on relations with her partner and surroundings; 3) the interaction between pregnancy and the HIV-positive status; 4) the relation between mother and children after birth and during the first few months of life. 56.25% of the women interviewed had become infected by intravenous drug injection, 25% through heterosexual relationships and 12.5% through blood transfusions. The cause was unspecified in 6.25%. The women had been aware of their HIV-positive status for between one and four years. Their reactions to HIV-positive status were predominantly denial, condemnation, and depression accompanied by a sense of death, anxiety and of being different. Relations between couples were influenced in a variety of ways by the new situation: 4 women reported a diminished frequency of sexual relations, one women reported reduced libido, 10 women did not notice changes in sexual relations and one woman did not reply.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological aspects of therapeutic abortion after early prenatal diagnosis.

The early discovery of a fetal pathology creates a "crisis" situation fraught with psychic problems for the couple who must live through it. The Authors observed a group of patients in the second trimester of pregnancy. They had all requested therapeutic abortion since serious malformation of the fetus had been confirmed. By means of a questionnaire constructed for the purpose, certain characteristics of fetal malformation and of pregnancy were evidenced, as well as the way these were experienced by the patients. The immediate and delayed reactions to the diagnosis of malformation were also studied, as was the experience lived when faced with the choice of abortion.

PIP: The psychological aspects of therapeutic abortion after early prenatal diagnosis of a fetal pathology among 50 2nd trimester (16th-22nd week) patients at the University of Rome obstetric clinic are described. A crises is experienced after discovery of a fetal pathology (e.g., chromosomic, dismetabolic, infectious, and multifactorial). An open ended questionnaire format was used to obtain information on the malformations and to solicit responses to the malformation and the choice to abort. Respondents' average age was 32, and all educational levels and job types were represented. 80% of malformations had a low recurrence risk of 2-3%, and 20% had a high risk of 25-50%. 42% were planned pregnancies and 36% were desired; 22% occurred by chance. 44% had previous healthy children. 22% were in a 1st pregnancy and 10% were in a 2nd pregnancy following an abortion. 14% had both healthy and handicapped children. Visual representation of the expected child was clear to 44%, unclear to 44%, and unimaginable to 12%. Only 26% had programmed a future for the child. 82% had a clear view of themselves as mothers, while 18% were vague. 76% had confident maternal attitudes toward child rearing. 76% considered the pregnancy to be organically easy. 16% felt it was decidedly difficult, and 8% had some difficulty. 60% felt emotionally comfortable with the pregnancy. 38% felt ambivalent, of which 80% had high-risk pregnancies. After notification of the malformation or suspicion, 90% felt emotionally aroused. 22% felt anxiety, particularly if the extent and gravity were not indicated; 18% felt amazement and 8% rejection. 14% rebelled. Examples of the exact responses are given. The reasons for choosing abortion are also given, ranging from being against abortion, but finding the malformation to be incompatible with life, to not wanting to inflict the consequences on other family members. 80% considered abortion as an option to limit the frustration and disappointment to a short period in their lives and to prevent repercussions. After the decision is made, the focus turns to the immediate aspects of the abortion.

Severe hypoplasia of the right femur, ipsilateral agenesia of the fibula and twisted right foot in a 24-week-old fetus with proximal femoral focal deficiency (PFFD).

A case of a 24-week-old fetus of non consanguineous parents with an ultrasonographic diagnosis of a short right femur, ipsilateral agenesia of the fibula and a twisted right foot is described. Cordocentesis revealed a normal 46XY karyotype. The parents were informed on treatment options and after psychological counselling they decided to undergo an abortion. Post mortem examination confirmed the diagnosis of a severe right limb malformation.

Long-term maintenance of sustained virological response in liver transplant recipients treated for recurrent hepatitis C.

BACKGROUND: The recurrence of hepatitis C viral infection is common after liver transplant, and achieving a sustained virological response to antiviral treatment is desirable for reducing the risk of graft loss and improving patients' survival. AIM: To investigate the long-term maintenance of sustained virological response in liver transplant recipients with hepatitis C recurrence. METHODS: 436 Liver transplant recipients (74.1% genotype 1) who underwent combined antiviral therapy for hepatitis C recurrence were retrospectively evaluated. RESULTS: The overall sustained virological response rate was 40% (173/436 patients), and the mean follow-up after liver transplantation was 11±3.5 years (range, 5-24). Patients with a sustained virological response demonstrated a 5-year survival rate of 97% and a 10-year survival rate of 93%; all but 6 (3%) patients remained hepatitis C virus RNA-negative during follow-up. Genotype non-1 (p=0.007), treatment duration >80% of the scheduled period (p=0.027), and early virological response (p=0.002), were associated with the maintenance of sustained virological response as indicated by univariate analysis. Early virological response was the only independent predictor of sustained virological response maintenance (p=0.008). CONCLUSIONS: Sustained virological response achieved after combined antiviral treatment is maintained in liver transplant patients with recurrent hepatitis C and is associated with an excellent 5-year survival.

Metabolic syndrome and cardiovascular risk after liver transplantation: a single-center experience.

Excessive weight gain, hypertension, hyperlipidemia, and diabetes are frequently observed among orthotopic liver transplantation (OLT) patients. These alterations, which are probably multifactorial in origin, contribute to posttransplantation metabolic syndrome (PTMS), which increases the risk of cardiovascular events. We assessed the prevalence of PTMS (diagnosed according to modified NCEP Adult Treatment Panel III criteria) in 156 OLT patients undergoing regular follow-up after transplantation (median 68 months; range, 6 to 234 months). Several pre- and post-OLT data were collected to identify the factors associated with the presence of PTMS which was found in 28% of cases. The only independent predictive factors for PTMS were diabetes mellitus and patients who were overweight or obese before-OLT. The prevalence of PTSM was lower among patients on tacrolimus immunosuppression. In our population, 21% of patients showed a high cardiovascular risk score with a 4% incidence of cardiovascular events, which was higher among subjects with PTMS. Close follow-up is mandatory to prevent the development of PTMS mainly among overweight and diabetic patients before transplantation.

Conversion from twice-daily to once-daily tacrolimus administration in liver transplant patient.

BACKGROUND: Compliance to immunosuppressive therapy is critical to prevent organ rejection and possible graft loss. A once-daily Tacrolimus formulation that may improve adherence-to-therapy while allowing the same patient care strategies, total daily dose and monitoring techniques that have been recently approved. The present study was sought to evaluate the feasibility of this formulation among liver transplantation patients (OLT). MATERIALS AND METHODS: Patients transplanted for at least 6 months were enrolled if they had stable doses of Tacrolimus over the last 3 months. Conversion from a twice to a once-daily regimen was based on a 1 mg:1 mg proportion. Tacrolimus blood levels were assessed at 0, 15, 30, 60, 90 days as well and 6 months after conversion. We recorded liver and renal function as well as adverse events. RESULTS: Among twenty-eight patients enrolled in the study including 23 males and 5 females the overall mean age was 59 +/- 8 years and the mean distance from OLT was 39 +/- 22. 32% of patients did not require any dose adjustment. In contrast, 43% required an increase (+0.6 +/- 0.3 mg/d), while 25%, a decrease (-0.5 +/- 0.0 mg/d) in the drug dose to maintain the same tacrolimus blood concentrations as at baseline. Ninety percent of patients stabilized blood levels within 45 days. None of the patients experienced adverse events or alterations in liver function. CONCLUSIONS: Our study confirmed that once-daily Tacrolimus is a useful therapeutic option for OLT patients; however dose adjustments are frequently needed in the short term. The drug is safe and may improve patient compliance.

Bone disorders in patients with chronic liver disease awaiting liver transplantation.

BACKGROUND: An important complication of chronic liver disease is osteodystrophy, which includes osteoporosis and the much rarer osteomalacia. Both conditions are associated with significant morbidity through fractures resulting in pain, deformity, and immobility. Liver transplantation may further deteriorate bone metabolism. The aim of the present study was to investigate the frequency and severity of hepatic osteodystrophy among patients with liver cirrhosis who were referred for liver transplantation. We also evaluated modifications in bone metabolism after liver transplantation. MATERIALS AND METHODS: We recruited 35 consecutive patients with chronic liver disease who were undergoing assessment for transplantation over a 1-year period. Bone mass in the total skeleton and proximal hip was evaluated using a dual-energy X-ray absorptiometry device (Lunar Prodigy Advance, GE Healthcare, USA). According to World Health Organization recommendations, osteoporosis was defined as a T score < -2.5 and osteopenia as T score between -1 and -2.5. RESULTS: We enrolled in the study 35 patients, including 8 females and 27 males of overall mean age of 57 +/- 7, who showed a viral etiology (57%) or alcohol etiology (28%), Child-Pugh 8.7 +/- 2.3. The overall prevalence of osteodystrophy was 40% (26% osteopenia and 14% osteoporosis). No difference was evident according to gender, severity of liver disease (Child-Pugh, Model for End-stage Liver Disease), or origin of liver disease. A subgroup of 10 transplanted patients reached 3-month follow-up, showing total body T score with a significant decrease after 3 months while femoral T scores tended to decrease insignificantly. CONCLUSIONS: This study revealed a high prevalence of low bone mineral density among cirrhotic patients before liver transplantation. We suggest that both bone mineral density and biochemical examinations should be considered to be routine tests to identify the status of bone mass and bone metabolism among recipients prior to liver transplantation.

Immune-mediated liver dysfunction after antiviral treatment in liver transplanted patients with hepatitis C: allo or autoimmune de novo hepatitis?

BACKGROUND: The recurrence of hepatitis C after liver transplantation is extremely frequent. Antiviral therapy combining pegylated-interferon with ribavirin is therefore increasingly used in these patients. It has been recently reported, however, that during antiviral treatment a hepatic immune-mediated liver dysfunction, similar to "de novo" autoimmune hepatitis, may develop in a few transplanted patients. PATIENTS AND METHODS: Three patients, treated with pegylated-interferon alpha-2a and ribavirin for recurrent hepatitis C after liver transplantation, developed an aggressive hepatitis with clinical, biochemical, and histological features similar to those of autoimmune hepatitis. RESULTS: In all three patients, a liver enzymes increase was evident after hepatitis C virus-RNA had become undetectable. Diagnosis of "de novo" autoimmune hepatitis was proposed, based on the presence of high-titre circulating autoantibodies and liver histology features. Following the introduction of a steroid therapy, clinical and biochemical parameters progressively improved. Hepatitis C virus infection, however, relapsed after a few months in all the patients. CONCLUSIONS: Following liver transplantation, antiviral therapy with pegylated-interferon alpha-2a and ribavirin for recurrent hepatitis C may be associated, in a few patients, with severe immune-mediated graft dysfunction similar to autoimmune hepatitis.

[Dietary fiber in the dietetic therapy of diabetes mellitus. Experimental data with purified glucomannans]. / Le fibre alimentari nella terapia dietetica del diabete mellito. Dati sperimentali con glucomannani purificati.

In the last years the use of alimentary fibres in dietetic management of diabetic patients increased. The aim of this work was to evaluate, in type 2 diabetic subjects, the glycaemic and insulinemic increments after a standard breakfast with glucomannanos enriched biscuits and with common slices of toast containing the same amounts of carbohydrates and calories. The basal serum values of glucose and C-peptide were similar in the two days of the test. The mean increments of glucose and C-peptide were significantly higher (p < 0.001) after slices of toast than after glucomannanos enriched biscuits. In conclusion our results show a reduction in glycaemic increments after breakfast with glucomannanos-biscuits. The decreased insulin secretion and the reduction of insulin need can longer preserve the functional reserve of beta-cells.

[The utility of postprandial C-peptide evaluation in type 2 diabetes]. / Utilità del C-peptide postprandiale nella valutazione del diabete tipo 2.

The secondary drug failure is a well known phenomenon in the development of type 2 diabetes mellitus, but an exact definition of this situation is still lacking. The aim of this research was to evaluate the beta-cell reserve in non obese diabetic patients in relation to the metabolic control and the duration of disease. The main aim was to identify values of postprandial plasma C-peptide that can characterize the patients requiring insulin treatment. A daily profile was performed in 135 non obese diabetic patients, within 20% of their ideal body weight. The mean diurnal values (m) and the mean post-prandial increases (delta mpp) of plasma glucose (G), insulin (IRI) and C-peptide (CP) were assessed. Fourty-four patients showed good (NwD-GC: G-m = 138 +/- 3.2 mg/dl) and 91 poor metabolic control (NwD-SF: G-m = 210 +/- 4.8 mg/dl), according to the G-m lower or higher than 150 mg/dl. Beta-cell reserve (CP-delta mpp: 0.70 +/- 0.03 vs 1.39 +/- 0.04 ng/ml) and C-peptide/insulin molar ratio (CP/IRA-delta mpp: 2.36 +/- 0.06 vs 2.80 +/- 0.06) were significantly lower (p < 0.001) in NwD-SF than in NwD-GC. NwD-GC and NwD-SF were respectively divided into three subgroups, according to the duration of disease. A progressive reduction of CP-delta mpp and an increase in SF prevalence, from the first to the third decade of diabetes duration, was observed. In both NwD-Gc and NwD-SF the duration of disease inversely correlated with CP-delta mpp (NwD-GC: y = 1.59-0.019X, p < 0.001; NwD-SF: y = 1.01-0.023X, p < 0.001). The analysis of the two regression lines showed that patients with CP-delta values lower than 1.0 ng/ml require insulin treatment. In conclusion the duration of diabetes and the progressive reduction of beta-cell reserve represent the major pathogenetic factors in secondary failure.