Subclinical atherosclerosis determinants in morbid obesity.

BACKGROUND AND AIMS: Obesity is associated with increased cardiovascular risk. However, the impact of morbid obesity on vascular structure and function is not well understood. This study was designed to appraise subclinical atherosclerosis markers, including carotid intima media thickness (cIMT), endothelial function, and arterial wall stiffness, and their determinants, in morbidly obese patients. METHODS AND RESULTS: In this cross-sectional study 194 overweight and obese patients were distributed in morbid-obese patients (MOP, n = 110), obese (OP, n = 84) and overweight patients (OwP, n = 33) groups. Demography, anthropometry, clinical and standard biochemical data were recorded. cIMT, endothelial function, defined as the small artery reactivity index (saRHI), and artery wall rigidity, studied by the augmentation index, were determined. More than 50% of the MOP, OP and OwP had a cIMT above the 75th percentile per age and gender. No differences in cIMT or saRHI were observed, although overweight and obese patients (OOP) had higher arterial rigidity compared with the morbid-obese patients. In a multivariate regression test, while cholesterol was the main determinant of cIMT in overweight and obese patients, glucose metabolism was the determinant in MOP. CONCLUSION: More than half of the population have a cIMT above general population ranges. OwP, OP and MOP have similar cIMT and saRHI. However, OOP have greater arterial wall rigidity. Dysglycemia is the main factor associated with subclinical atherosclerosis in MOP.

Influence of a monocyte chemoattractant protein 1 mutated allele on the response to protease inhibitor-based antiretroviral therapy.

BACKGROUND: Antiretroviral drug efficacy has been widely studied in relation to viral factors. Mutations in the HIV co-receptors and their natural chemokines, however, may be critical in HIV infection and treatment response. We compared the efficacy of protease inhibitor (PI) treatment among PI-naïve patients grouped according to whether they carried the chemokine CC motif receptor 2 (CCR-2) 64I and monocyte chemoattractant protein 1 (MCP-1)-2518G alleles. METHODS AND RESULTS: HIV-infected patients who were PI-naive were selected for the study (n=164) but there was no restriction on lymphocyte CD4 count or plasma HIV viral load. Follow-up was for the first 24 months of treatment. Clinical and laboratory data were obtained every 3 months. All the participants were genotyped for the MCP-1-2518G, CCR-2 64I, CCR-5Delta32 and stromal derived factor 1 (SDF1) 3'A mutated alleles. The results indicated that patients carrying the mutated allele of MCP-1 had a higher mean CD4 cell count throughout the follow-up period than those with the common allele (P=0.01). Also, patients with the MCP-1 and CCR-2 mutated alleles were more likely to continue to have an undetectable viral load following treatment (P=0.05). CONCLUSION: A better response to PI treatment appears to be conferred by mutations in the host MCP-1 and CCR-2 genes, and may be related to the cellular axis-of-entry used by the retrovirus.

Monoclonal antibody analysis of crescentic membranous glomerulonephropathy.

Idiopathic membranous glomerulonephropathy (MG) has a rather benign prognosis. Acute renal failure with cellular crescents superimposed on MG is unusual and its pathogenesis is not fully understood. We report 3 patients with crescentic MG who showed strong glomerular and interstitial infiltration of leukocytes (CD45), T lymphocytes (CD3), helper/inducer T cells (CD4), cytotoxic/suppressor T cells (CD8), and monocyte-macrophages (CD14). A similar number of CD4+ and CD8+ cells contributed to T cellularity within the glomerular tuft, whereas CD4+ cells were predominant over CD8+ cells in the crescents. Intercellular adhesion molecule-1 (ICAM-1) antigens (CD54) were found on renal vascular endothelium, interstitial cellular aggregates and proximal tubular epithelial cells. The case reports illustrate the contribution of macrophages and T cells bearing predominantly CD4+ phenotype to cellular crescents, and the abnormal expression of ICAM-1 antigens on proximal tubular epithelial cells. Both features suggest that cell-mediated immunity may play a role in the transformation of crescentic MG.

Effects of aspirin and Helicobacter pylori on the gastroduodenal mucosal permeability to sucrose.

BACKGROUND: A non-invasive marker is needed to identify patients with significant gastrointestinal injury due to non-steroidal anti-inflammatory drugs. Gastrointestinal permeability to sucrose has been suggested as such a test. AIMS: To assess the utility of sucrose permeability as a marker of gastroduodenal mucosal injury after single and multiple doses of aspirin, to identify the site of increased sucrose permeability, to explore the relation between sucrose permeability and endoscopic findings, and to evaluate whether Helicobacter pylori infection influenced gastroduodenal sucrose permeability. METHODS: After a fasting urine was obtained, 500 ml of a solution containing 100 g of sucrose was ingested. Urine was collected for five hours and assayed for sucrose by high performance liquid chromatography. Sucrose permeability was also assessed 20 minutes after ingestion of 650 mg of aspirin and eight to 12 hours after a 72 hour course of 650 mg aspirin four times a day. The site of increased permeability was identified after pyloric occlusion with a double balloon tube. RESULTS: Thirty seven healthy volunteers participated. Sucrose permeability (mean (SEM)) increased after both single (195.2 (27) mg and multiple (196.4 (31) mg) doses of aspirin compared with baseline (53.7 (10) mg; p < 0.0005). Balloon pyloric occlusion confirmed that the site of increased sucrose permeability was the stomach. The effect of aspirin on sucrose permeability was similar in those with and without H pylori infection. CONCLUSION: These results confirm the use of sucrose permeability as a marker of aspirin induced gastroduodenal mucosal injury and identify the stomach as the major site of increased permeability. H pylori infection does not seem to change gastric mucosal sucrose permeability either at baseline or after ingestion of aspirin.

Alpha 1-antitrypsin deficiency and chronic pancreatitis.

Alpha 1-antitrypsin deficiency is a genetic disorder commonly associated with pulmonary and hepatic injury. Low serum levels of this glycoprotein result in an imbalance between circulating protease and protease inhibitors, which is thought to play a role in the development of emphysema. In recent studies, a protease-to-protease inhibitor imbalance in patients with alpha 1-antitrypsin deficiency was thought to be a mechanism contributing to the development of chronic pancreatitis. The heterozygous phenotype and low levels of this glycoprotein have been reported to occur more frequently in patients with chronic pancreatitis than in healthy controls. We report a patient with Pi-SS phenotype alpha 1-antitrypsin deficiency and chronic pancreatitis complicated by recurrent pancreatic pseudocysts and chronic abdominal pain. Our case supports the association between chronic pancreatitis and alpha 1-antitrypsin deficiency. Furthermore, this case provides support for the use of pancreatic stent drainage in the management of intractable abdominal pain in patients with chronic pancreatitis and a dominant stricture.

Lipoma arborescens of the shoulder: magnetic resonance imaging findings.

Lipoma arborescens is a rare intra-articular lesion that typically affects the knee. This condition represents villous lipomatous proliferation of the synovial membrane. The magnetic resonance imaging findings are diagnostic and include a frond-like, fatty synovial mass and associated joint effusion. The authors describe a 90-year-old woman with lipoma arborescens of the shoulder. To the authors' knowledge, lipoma arborescens has not previously been reported in this joint.

Lead "bursogram" and focal synovitis secondary to a retained intraarticular bullet fragment.

We present an unusual case in which retained lead bullet in the wrist joint dissolved and migrated into a synovial recess, producing reactive focal synovitis. The clinical presentation suggested a soft tissue mass or ganglion cyst. The radiologic findings of dense metallic fragments within a recess of the wrist joint established the correct diagnosis and excluded other causes of soft tissue masses. Radiologic recognition of retained intra-articular lead fragments is important, as the clinical features of systemic lead intoxication, lead arthopathy, or reactive focal synovitis may be subtle or misleading.

CT of the spine: value of reformatted images.

Recent improvements in CT software allow rapid and high-quality two-dimensional reformatting of scans of the spine. Reformatting involves computer interpolation of two-dimensional multislice images acquired during routine axial CT scanning in order to generate a three-dimensional volume of data. From this block of data, new images are created and displayed in any desired plane. Reformatted images are acquired within minutes following axial CT scanning.

Viral pathogenesis of hepatocellular carcinoma in the United States.

Chronic hepatitis B virus infection is closely associated with the development of hepatocellular carcinoma, which is a major cause of cancer death worldwide. Recent studies have implicated hepatitis C virus infection as a major pathogenic agent of HBsAg-negative hepatocellular carcinoma. The significance of hepatitis C virus and hepatitis B virus infections in the occurrence of HBsAg-negative hepatocellular carcinoma has not been well established in the United States. We studied 91 HBsAg-negative American patients with hepatocellular carcinoma for evidence of hepatitis C virus or hepatitis B virus infection. These patients had no other predisposing factors to hepatocellular carcinoma. A sensitive polymerase chain reaction was employed to detect hepatitis C virus RNA and hepatitis B virus DNA in serum and liver. Three sets of hepatitis C virus and hepatitis B virus primers were used to optimize the detection of viral genomes. Hepatitis C virus antibodies were measured with second-generation immunoassays. Twenty-six (29%) of these patients carried low levels of hepatitis B virus DNA in either serum, liver/tumor tissue or both. On the basis of the results from serological and polymerase chain reaction analyses of serum and liver, we found that 53 of 91 patients (58%) exhibited evidence of hepatitis C virus infection. When data were combined, 14 patients (15%) had evidence of hepatitis B virus/hepatitis C virus coinfection, whereas 12 (13%) were infected with hepatitis B virus alone and 39 (43%) had hepatitis C virus only. Twenty-six (29%) had no markers of hepatitis B virus or hepatitis C virus infection.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of short-chain fatty acid metabolism in colonic disorders.

During the past decade it has become evident that colonic mucosal metabolism is more complex than previously suspected. Luminal short-chain fatty acids (SCFAs) are recognized as an essential fuel source for colonocytes, particularly in the distal colon. Their absence may explain the development of diversion colitis; however, this has not been confirmed by clinical trials. The histologic, endoscopic, and metabolic similarities between diversion colitis and ulcerative colitis suggest that a nutritional SCFA deficiency state may play a role in the pathogenesis of these disorders. Diversion colitis and continent urinary diversion, utilizing distal and proximal colon reservoirs, provide in vivo models to study normal colonic mucosa in circumstances of reduced intraluminal SCFA concentrations and altered luminal effluent. Further studies utilizing these models would enhance our understanding of the regional differences in mucosal cell metabolism and adaptability and, hopefully, provide therapeutic alternatives for the management of colonic disorders. The welfare of colonic mucosa, as it relates to SCFA metabolism, awaits another exciting decade of investigation.

Massive epistaxis due to pseudoaneurysm. Treated with detachable balloons.

A case of massive epistaxis refractory to nasal packing and bilateral surgical ligation of the internal maxillary and ethmoidal arteries is presented. Angiography revealed a pseudoaneurysm of the cervical portion of the internal carotid artery, and intravascular detachable balloons were used for epistaxis control. The appropriate use of intravascular diagnostic and therapeutic techniques is described.

Aberrant insertion of the common bile duct into an accessory pancreatic duct: cholangiographic demonstration.

Variations in the pancreatic ductal anatomy result from abnormalities in embryological development of the pancreas from ventral and dorsal buds. We describe a case in which cholangiography demonstrated insertion of the common bile duct into an aberrant pancreatic duct. To our knowledge, this finding has not been previously reported in the literature.

Antibody to hepatitis C is common among patients with alcoholic liver disease with and without risk factors.

Thirty-seven patients with clinically suspected alcoholic liver disease were retrospectively studied for the prevalence of antibody to hepatitis C virus (HCV) by enzyme-linked immunosorbent assay (ELISA) and immunoblot assay. Twenty-four had biopsy-proven cirrhosis. Nineteen had identifiable risk factors for non-A, non-B viral hepatitis, and 18 did not. Five of 19 high-risk (26%) and 6 of 18 low-risk (33%) patients had positive antibody, compared with two of 179 healthy blood donors (p less than 0.01 for either group of alcoholics compared with blood donors). Nine of 11 ELISA-positive patients were also either positive or indeterminable by immunoblot testing. Histologic scores for parameters commonly associated with chronic viral hepatitis were numerically worse among anti-HCV-positive patients, but none reached statistical significance. Clinically, seven of 11 (64%) of anti-HCV-positive patients versus 14 of 26 (54%) anti-HCV-negative patients were Child's class C. Among the 21 Child's class C patients, seven (33%) were anti-HCV-positive versus four of 16 (25%) of Child's class A/B patients. A weak correlation between IgG and ELISA optical density was observed (r = 0.52). We conclude that antibody to hepatitis C by ELISA and immunoblot is common among alcoholics with liver disease even in the absence of known or suspected risk factors for viral hepatitis. Although hepatitis C-positive patients tended to have more severe histologic disease, neither histologic parameters nor clinical findings were adequate to predict antibody seropositivity.

Detection of subarachnoid pleural fistula.

A case of subarachnoid-pleural fistula detected by radionuclide myelography is reported. Review of the literature shows that radionuclide myelography is proving to be more sensitive than contrast myelography in confirming the diagnosis.