Long-term therapy with adefovir dipivoxil in hepatitis B e antigen-negative patients developing resistance to lamivudine.

BACKGROUND: The efficacy of long-term adefovir dipivoxil monotherapy or combination of adefovir and lamivudine in hepatitis B e antigen (HBe-Ag)-negative lamivudine-resistant chronic hepatitis B (CHB) patients is still under investigation. AIM: To assess the safety and efficacy of the long-term adefovir treatment alone or in combination with lamivudine in HBe-Ag-negative CHB patients who had developed breakthrough because of lamivudine-resistant mutants. METHODS: Fifty-nine patients received combination therapy, while 23 switched to adefovir alone after a 3-month course of combination therapy. RESULTS: The median follow-up after adefovir's onset was 31 (18-40) months. Baseline characteristics were similar between the two groups. At 12 and 24 months, 69% and 89% of patients receiving combination therapy and 73% and 82% of patients receiving adefovir monotherapy had serum HBV-DNA <10(4) copies/mL (P > 0.5). Normalization of alanine aminotransferase levels occurred in 81% and 79% of patients receiving combination vs. 61% and 53% receiving adefovir monotherapy at 12 and 24 months, respectively (P > 0.50). Virological breakthroughs because of adefovir-resistant mutants occurred in five patients under adefovir monotherapy and in none receiving combination therapy (P = 0.001). No one developed decompensated liver disease or hepatocellular carcinoma during follow-up. Re-introduction of lamivudine in adefovir-resistant patients achieved reduction in HBV-DNA and biochemical remission, but re-emergence of lamivudine mutants was observed in one patient after 7.5 months. CONCLUSION: In HBe-Ag-negative CHB patients with lamivudine resistance, adding adefovir to continuing lamivudine therapy maximizes anti-viral efficacy because of absence of viral resistance.

Is preservation of the adrenal vein mandatory in laparoscopic adrenal-sparing surgery?

BACKGROUND AND OBJECTIVE: Adrenal tissue-sparing or partial adrenalectomy evolved initially for patients with bilateral synchronous adrenal surgical pathology to preserve vital adrenal volume. In the laparoscopic era, the exact criteria for performing such procedures laparoscopically have yet to be defined. Controversy exists regarding the importance of preserving the adrenal vein, main or accessory. The aim of this retrospective study was to present our short series of laparoscopic tissue-sparing adrenalectomies with vein preservation. Our main goal is not to support partial adrenalectomy as an alternative to total (this is already advocated by many surgeons) but to emphasize the vein-preserving technique. METHODS: Seven patients with peripherally located either aldosterone-producing adenomas (4 cases) or myelolipomas (4 cases) underwent laparoscopic lateral partial adrenalectomy. One patient harbored an aldosterone-producing adenoma and a myelolipoma as well. The main adrenal vein was identified and preserved in 6 patients and the accessory vein in one. RESULTS: No conversion to open adrenalectomy was necessary, and no perioperative morbidity or mortality occurred. Three adenoma patients are normotensive 44, 23, and 20 months postoperatively, while the fourth one's pressure is refractory. CONCLUSIONS: Surprisingly, total adrenalectomies preceded the partial ones, which is controversial compared with other procedures. Laparoscopic lateral partial adrenalectomy is a technically challenging tissue-sparing operation. Meticulous dissection allows preservation of the middle artery and main or accessory vein resulting in a functioning adrenal stump.

Feasibility of laparoscopic adrenalectomy for large pheochromocytomas.

BACKGROUND AND OBJECTIVES: The majority of surgeons consider large and potentially malignant pheochromocytomas an absolute contraindication for laparoscopic adrenalectomy (LA). The aim of this study was to evaluate the risks and outcomes of LA in patients with this anomaly. METHODS: Five patients (2 males, 3 females) with large (>6 cm) pheochromocytomas were selected. Preoperative investigation demonstrated no evidence of invasive carcinoma. All patients received alpha-blocker preparation for at least 20 days. Laparoscopic adrenalectomy via a lateral transperitoneal approach was performed in all cases. RESULTS: Patient's median age was 48 years, and the median tumor size was 10.8 cm. No capsular disruption and no hypertensive crises occurred during the operation. The median operating time was 148 minutes and blood loss was <150 mL. Conversion to open adrenalectomy occurred in 2 patients owing to intraoperative evidence of carcinoma. No postoperative morbidity or mortality occurred. All patients are disease free after a median follow-up of 13 months. CONCLUSIONS: In experienced hands, LA can be proposed for large and potentially malignant pheochromocytomas. Conversion to open adrenalectomy is mandatory if local invasion, capsular disruption, or technical difficulties are observed during the operation.

Lamivudine monotherapy in HBeAg-negative chronic hepatitis B: prediction of response-breakthrough and long-term clinical outcome.

BACKGROUND: Factors that predict response and breakthrough phenomenon to lamivudine monotherapy in patients with HBeAg-negative chronic hepatitis B have not been well defined. AIM: To determine pre-treatment and on treatment variables that predict initial response and breakthrough in patients with HBeAg-negative chronic hepatitis B receiving long-term lamivudine. METHODS: Seventy-nine patients, with chronic HBeAg-negative hepatitis B, who received lamivudine for a median of 31 months were included in the study. RESULTS: Initial virologic and biochemical response was observed in 73 (92%) and 70 (89%) patients, respectively, while 34 (47%) and 15 (21%) patients developed virological and biochemical breakthrough, respectively. High levels of necroinflammation in liver biopsy were associated with a higher probability of initial virological and biochemical response. Patients with pre-treatment serum hepatitis B virus DNA concentrations of more than 10(6) copies/mL were three times more likely to develop virologic breakthrough. Two patients died, one with baseline cirrhosis because of liver failure during biochemical breakthrough while the second death was liver and treatment unrelated. CONCLUSIONS: In HBeAg-negative chronic hepatitis B, initial response to lamivudine therapy is associated with necroinflammation, while baseline serum hepatitis B virus DNA exceeding 10(6) copies/mL is a strong predictor for breakthrough because of drug-resistant mutations. Severe complications are uncommon and are associated with biochemical breakthrough and pre-existing cirrhosis.

Clinical significance of cytotoxin-associated gene A status of Helicobacter pylori among non-steroidal anti-inflammatory drug users with peptic ulcer bleeding: a multicenter case-control study.

BACKGROUND: The role of Helicobacter pylori infection and especially of the cytotoxin-associated gene A (CagA) product strain in peptic ulcer bleeding among non-steroidal anti-inflammatory drugs (NSAIDs) users remains controversial. METHODS: A case-control study was carried out including 191 consecutive chronic NSAIDs users admitted to hospital because of peptic ulcer bleeding. Peptic ulcer was verified by endoscopy. Controls comprised 196 chronic NSAIDs users without signs of bleeding of similar age and gender to cases. Multivariate regression analysis was performed for further evaluation of the relationship between H. pylori, CagA status and other risk factors. RESULTS: H. pylori infection was present in 121 (63.4%) cases compared with 119 (60.7%) controls (odds ratio (OR) = 1.14, 95% CI, 0.76-1.72). CagA-positive strains were found to be significantly more frequent in cases than in controls (65/106 versus 41/99 P = 0.008). Current smoking (OR = 2.65; 95% CI, 1.14-6.15; P= 0.02), CagA status (OR = 2.28; 95% CI, 1.24-4.19; P = 0.008), dyspepsia (OR = 6.89; 95% CI, 1.84-25.76; P = 0.004) and past history of peptic ulcer disease (OR=3.15; 95% CI, 1.43-6.92; P=0.004) were associated significantly with increased risk of bleeding peptic ulcer. CONCLUSIONS: The results suggest that CagA-positive H. pylori infection is associated with a more than 2-fold increased risk of bleeding peptic ulcer among chronic NSAIDs users.

Ceramic processing of incinerator bottom ash.

The <8 mm fraction of aged incinerator bottom ash from a commercial incinerator (energy from waste) plant has been collected at regular intervals, characterised and processed to form ceramic materials. Ashes were sieved, wet ball milled, dried, compacted and sintered at temperatures between 1080 and 1115 degrees C. Variations in the chemical composition and mineralogy of the milled ash, and the mineralogy, physical properties and leaching of sintered products have been assessed. Milling produces a raw material with consistent chemical and mineralogical composition with quartz (SiO(2)), calcite (CaCO(3)), gehlenite (Ca(2)Al(AlSi)O(7)) and hematite (Fe(2)O(3)) being the major crystalline phases present. Different batches also milled to give consistent particle size distributions. Sintering milled incinerator bottom ash at 1110 degrees C produced ceramics with densities between 2.43 and 2.64 g/cm(-3) and major crystalline phases of wollastonite (CaSiO(3)) and diopside (CaMgSi(2)O(6)). The sintered ceramics had reduced acid neutralisation capacity compared to the as-received ash and exhibited reduced leaching of Ca, Mg, Na and K under all pH conditions. The leaching of heavy metals was also significantly reduced due to encapsulation and incorporation into glassy and crystalline phases, with Cu and Al showing greatly reduced leaching under alkali conditions.