Late occurrence of pleural and peritoneal effusion due to Mycobacterium tuberculosis infection (TB) in a patient with posttransplantation recurrent HCV chronic hepatitis: safety of peginterferon and ribavirin treatment after recovery of TB:- a case report.

The late occurrence of a large and often long-lasting effusion in the pleural and peritoneal cavities after liver transplantation is an uncommon and poorly understood complication. Even rarer (<1%) is the incidence of Mycobacterium tuberculosis (MT) in Western world series. Herein we have described a case of massive pleural effusion and ascites due to MT occurring 22 months after liver transplantation for hepatitis C virus (HCV) cirrhosis. The infection was successfully treated with no hepatotoxicity or rejection, so that it was possible to start antiviral treatment with peginterferon and ribavirin for recurrent HCV without reactivation of MT infection.

Sensitivity of diagnostic examinations for colorectal polyps.

The removal of adenomatous polyps of the large bowel reduces mortality from colorectal cancer (CRC). Faecal occult blood testing only reveals 20.40% of polyps. The flexible rectosigmoidoscope explores less than half of the large bowel. Its use should always be coupled with faecal occult blood testing which, if positive, requires a total colonoscopy. The sensitivity of double-contrast barium enema for the search of polyps is 35%. Colonoscopy does not reach the caecum in about 10% of cases. It misses 15-20% of polyps with diameter <10 mm and about 6% of polyps with diameter >10 mm. Virtual colonoscopy has substantially the same sensitivity as optical colonoscopy for polyps > or =7 mm in diameter.

Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure; the OSCUR study. Oucome dello Scompenso Cardiaco in relazione all'Utilizzo delle Risore.

AIMS: This study was designed to identify potential specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for congestive heart failure in departments of cardiology or internal medicine. METHODS AND RESULTS: From 1 July to 31 December 1998, we prospectively recorded epidemiological and clinical data from patients with congestive heart failure consecutively admitted to 11 departments of cardiology and 12 departments of internal medicine in Liguria, a northern area of Italy. The overall study population included 749 patients; 22% were treated by cardiologists and 78% by internists (P<0.0001). Patients managed by cardiologists were more likely to undergo echocardiography (92% vs 37%), Holter monitoring (25% vs 3%) and exercise stress testing (20% vs 0.5%) than those managed by internists (P=0.001). At discharge, patients treated by cardiologists were more likely to be prescribed beta-blockers (41% to 4%) and ACE inhibitors (100% to 74%) than those treated by internists (P<0.0001), and the latter medication at higher dosages by cardiologists than internists. In addition, patients followed by cardiologists were younger (70+/-9 to 79+/-1 years;P<0.0001), more likely to be male (61% to 50%;P=0.011) and to have coronary artery disease (57% to 45%;P<0.006) than those followed by internists. Conversely, patients followed by internists were more likely to have diabetes, chronic obstructive pulmonary disease, atrial fibrillation and renal failure (P<0.03). In the overall study population, 53 patients (7%) died during hospitalization. Patients treated by cardiologists had a mortality not significantly different from that of patients treated by internists (10% and 6%, respectively;P=0.067), although congestive heart failure was more severe on admission in patients treated by cardiologists. CONCLUSION: Cardiologists follow published guidelines for congestive heart failure more strictly than internists, but treat a smaller number of patients who are younger, have more severe congestive heart failure and fewer co-morbidities than those managed by internists.

[Ceftazidime in the treatment of Weil's disease] / Ceftazidime nel trattamento del morbo di Weil.

We present a case report of leptospirosis with acute renal failure and hepatic dysfunction. Aspecific clinical presentation and serologic tests do not help therapeutic choices. The patient received 18 sessions of hemodialysis and early treatment with intravenous ceftazidime 1 g tid (under the impression of Gram- sepsis). Third generation cephalosporins, ceftriaxone and cefotaxime, are highly active against Leptospira [10] while clinical experience with ceftazidime is lacking.

Interferon retreatment in chronic hepatitis C: which patients to choose, and what schedule to use.

UNLABELLED: OBJECTIVE; To evaluate the results of a large cohort of non-responder or relapsing responder patients with chronic hepatitis C retreated with various schedules of interferon (IFN). METHODS: Our study included 276 patients (158 non-responders and 118 relapsing responders) who underwent IFN retreatments. Among the non-responder group, 158 patients underwent further courses of IFN. In particular, 108 patients underwent one course of IFN retreatment, 40 patients underwent two courses, eight patients underwent three courses, and two patients underwent four courses. Regarding the relapsing responder group, the 118 patients were retreated with the same dosage for varying periods. In particular, 50 patients were treated for 6 months, 43 patients for 12 months, and 25 for 24 months. Patients in the subgroups of IFN retreatment were homogeneous as far as age and gender distribution, as well as virological and histological characteristics, are concerned. Qualitative and quantitative HCV-RNA was evaluated at baseline, at the end of treatment and at the last check-up of follow-up. HCV genotype was determined on baseline serum samples. Alanine transaminase (ALT) levels were tested monthly. RESULTS: Long-term biochemical (normal ALT levels) and virological (HCV-RNA negative) response was obtained in 2.6% of non-responder retreated patients, and in 33.9% of relapsing responder retreated patients. Evaluation of response on the basis of the duration of treatment showed that 48%, 19% and 16% of relapsing responder patients retreated for 24, 12 and 6 months, respectively, obtained long-term biochemical and virological response. CONCLUSION: Non-responder patient retreatment is inefficient especially in cirrhotic and/or genotype 1 b patients. IFN retreatment is warranted in relapsing responder patients. In particular, 24-month therapy induces significant long-term biochemical and virological response.

[Port malaria caused by Plasmodium falciparum a case report]. / Malaria portuale da Plasmodium falciparum: descrizione di un caso clinico.

A case of unusual transmission by Plasmodium falciparum malaria is reported. The patient, had not been travelling outside North-West of Italy for the previous 6 months, he was not drug abuser. He had spent the last two months prior his admission, partly in his home town, an urban area in the region of Piemonte, and partly in a resort area on the Ligurian sea. Neither place has ever been associated with unusual malaria transmission. The possible transmission way is through a live vector imported from endemic area in a port terminal near a resort area.

[The gastric anatomico-functional aspects (parietal cell mass, stimulated acid secretion and gastrinemia) in pernicious anemia]. / Aspetti anatomo-funzionali gastrici (massa cellulare parietale, secrezione acida stimolata e gastrinemia) in corso di anemia perniciosa.

We present here a study of parietal cell mass, stimulated acid secretion and basal gastrinemia both in the course of isolated chronic atrophic gastritis of the body-fundus and in chronic atrophic gastritis of the body-fundus associated with pernicious anemia. Analysis of our results evidences an overlapping cyto-secretory profile characterized by hypoparietalism with hypo-achlorhydria. The higher basal gastrinemia levels in pernicious anemia depend on the histological status of the antral mucosa--which was always normal in the patients with pernicious anemia--rather than any substantial morpho-functional differences of the body-fundus. We thus conclude that the term "atrophic gastritis" should be abolished, and that the term "chronic atrophic gastritis" be used to describe both conditions.

[The renin-angiotensin-aldosterone system in liver cirrhosis]. / Il sistema renina-angiotensina-aldosterone nella cirrosi epatica.

The role of the RAA system in the genesis of ascites in liver cirrhosis patients is not yet perfectly clear. The present study was conducted on 176 cirrhosis patients in order to investigate RAA system function, to assess the changes taking place in the various stages of the disease and to correlate such changes with the various kidney function parameters. The patients were divided into 3 groups as follows: Group I: patients without ascites on admission and with no history of the condition; Group 2: patients with ascites of recent onset and/or response to diuretic treatment; Group 3: patients with ascites not responsive to diuretic treatment. In Group 1, 19 patients (38%) reveal a significant reduction in renin activity together with portal hypertension and increased hydrosaline retention. In Group 2 renin activity was reduced in 4 patients (6%), aldosterone activity in 3 (4%). Progressive deterioration in liver function parameters and progressive activation of the RAA system combined with reduced sodiuria content were found in over 50% of these patients. The presence or absence of portal hypertension in this group was not related to significant changes in diuresis or sodiuria. In Group 3 renin was activated in 54 patients (89%), aldosterone in 58 (95%) and there was also a distinct reduction in sodiuria (96% of patients) and chloruria (100%). A substantial increase was also noted in the incidence of low blood sodium (53%) while portal hypertension was found in 97% of patients. On the basis of those data it may be hypothesised that high pressure inside the liver creates the stimulus for primary sodium retention. The decrease in effective blood volume after vasodilation, accentuated by low blood albumin and splanchnic venous stagnation may the stimulate the sympathetic nervous system and RAA system. Hyperaldosteronism only becomes the dominant factor in renal imbalance when the cirrhosis reaches the resistant ascites phase.

[Changes in antidiuretic hormone (ADH) in liver cirrhosis with resistant ascites]. / Modificazioni dell'ormone antidiuretico (ADH) nella cirrosi epatica con ascite resistente.

The pathogenetic role of ADH in determining hyponatremia in patients with liver cirrhosis is still much debated. Osmotic stimuli are not able to inhibit secretion of ADH in refractory ascites and under such conditions the reduction in effective plasma volume has been put forward as the main cause. Twenty patients with liver cirrhosis and refractory ascites were studied before and during extraction-concentration-reinfusion (ECR) of ascitic fluid by means of Rhodiascit. ADH, renin, aldosterone, blood and urine osmolarity, plasma and urinary concentration of sodium, potassium, chlorine, and the clearance of free water were evaluated. All patients presented high renin values (15.4 +/- 11.7 ng/ml), aldosterone (341 +/- 172 ng/ml), ADH (6.3 +/- 5.2 pg/ml). During ECR, a significant drop was observed in renin (p less than 0.001), aldosterone (p less than 0.001) urinary osmolarity (p less than 0.001) and an equality significant increase in diuresis (p less than 0.001), natriuria (p less than 0.005), kaliuria (p less than 0.001) while ADH presented an irregular course: in 11 cases it remained unchanged, in 3 it fell and in 6 it presented a constant increase. To conclude, data suggest that the diminished filtrate reaching the distal tubule constitutes the greatest cause of the inability to dilute urine in many patients with cirrhosis and that ADH is a permissive rather than a primary factor.

Comparison between single morning and bedtime doses of 40 mg famotidine for the treatment of duodenal ulcer.

The aim of this study was to compare the duodenal ulcer healing effects of morning (08.00 hours) vs. single bedtime (22.00 hours) doses of 40 mg famotidine, bearing in mind that the known efficacy of bedtime doses of H2-antagonists is regarded as evidence of the predominance of nocturnal gastric acidity in the pathogenesis of duodenal ulcer. This randomized double-blind multicentre trial was conducted in a total of 127 patients with endoscopically proven active duodenal ulcer. Nine patients dropped out and thus 118 were included in the final analysis. The duration of treatment was 4 weeks, and this was extended to 8 weeks in patients whose ulcers failed to heal by week 4. The patients in the two treatment groups were well matched for age and sex. The therapeutic efficacy parameters were endoscopic healing of the ulcer lesion and disappearance of pain. Results were compared using the chi-square method. The 4- and 8-week (cumulative) ulcer healing rates in the patients treated with the morning dose of famotidine were 77.2% and 86%, respectively, compared with 78.6% and 91.8% in those who received the bedtime dose. The differences failed to prove statistically significant either at week 4 (P = 0.85) or at week 8 (P = 0.31). The percentages of patients with ulcer pain, evaluated weekly, were similar in the two treatment groups. The equivalent efficacy of the morning and bedtime famotidine regimens raises doubts concerning the predominance of nocturnal gastric acidity in the pathogenesis of duodenal ulcer.

Large-bowel transit in paraplegic patients.

Severe constipation often follows spinal cord injury. The aim of this study was to evaluate transit of contents through the large bowel in patients with paraplegia after a complete transverse lesion of the spinal cord. Transit through the right colon, left colon, and rectum was evaluated in 11 patients (eight males, 3 females; 17 to 63 years old) and data were compared with that of 37 healthy control subjects. In all patients there was either no, or abnormally low, transit at the level of the left colon and rectum. A minor degree of transit delay at the level of the right colon was also present in eight patients. These data indicate that constipation in patients with paraplegia is due to abnormal transit, mainly at the level of the left colon and rectum, and transection of the spine between the C-4 and T-12 vertebral levels causes alteration of large-bowel motor activity mainly at the level of the segments innervated by the parasympathetic fibers of the sacral outflow.

Cimetidine, 800 mg at night versus 400 mg twice daily, in the treatment of duodenal ulcer.

A multicentre double-blind study was carried out on a total of 197 patients, to evaluate the safety and efficacy of an 800 mg nighttime dose of cimetidine in comparison with 400 mg twice daily in the treatment of duodenal ulcer. At 4 weeks 84% of the 187 patients eligible for analysis had healed ulcers with the once daily regimen and 68% with the twice daily regimen (p less than 0.05). An early decrease in both day and nighttime pain and in antacid consumption was observed during the first 2 weeks. Adverse effects were few and mild, confirming the safety profile of cimetidine.

Comparison of cimetidine 800 mg once daily and 400 mg twice daily in acute duodenal ulceration.

A double blind trial was conducted in seven centres to evaluate the safety and efficacy of cimetidine 800 mg given at night compared with 400 mg given at breakfast and at bedtime. Altogether 197 patients with active duodenal ulcer confirmed by endoscopy entered the study, of whom 187 were eligible for analysis. After four weeks' treatment the ulcer was healed in 76 of 91 patients (84%) receiving the once daily regimen and in 65 of the 96 patients (68%) receiving the twice daily regimen (p less than 0.05). Both dosage regimens were equally effective in reducing ulcer pain and consumption of antacids. Pain relief was considerable within the first two weeks, and most of the patients were free of symptoms by the end of treatment. No patients were withdrawn because of adverse events as these were few and mild, consistent with the proved safety profile of cimetidine. Cimetidine 800 mg given at night is as effective as 400 mg twice daily; the single dose regimen may improve patient compliance, thus facilitating treatment.

[The importance of thyroid hormone determination in the course of acute and chronic liver diseases]. / Importanza del dosaggio degli ormoni tiroidei in corso di epatopatie acute e croniche.

The RIA values of thyroid hormones in the course of acute and chronic liver disease were studied to see whether they were related to the severity of the picture in a series of 50 healthy subjects and 133 with various hepatopathies: 26 with acute viral hepatitis, 18 with alcoholic liver disease, 16 with alcoholic cirrhosis without ascites and 33 with ascites, 14 non-alcoholic cirrhosis without ascites and 24 with ascites. A reduction in T3 proportional to the seriousness of the clinical and laboratory findings was noted in chronic forms, whereas both T3 and T4 were high in acute viral hepatitis. There was no difference in T3 values in alcoholic and non-alcoholic cirrhosis of similar gravity, showing that the fall in serum T3 is not a specific alcohol-induced lesion. T3 less than 25 ng/100 ml proved the best index in the prediction of mortality (chi 2 = 20,5; p less than 0,0005).