Assessing the impact of structured reporting on learning how to report lung cancer staging CT: A triple cohort study on inexperienced readers.

PURPOSE: To assess the clinical utility of chest computed tomography (CT) reports for non-small-cell lung cancer (NSCLC) staging generated by inexperienced readers using structured reporting (SR) templates from the Royal College of Radiologists (RCR-SR) and the Italian Society of Medical and Interventional Radiology (SIRM-SR), compared to traditional non-systematic reports (NSR). METHODS: In a cohort of 30 NSCLC patients, six third-year radiology residents reported CT examinations in two 2-month-apart separate sessions using NSR in the first and NSR, RCR-SR, or SIRM-SR in the second. Couples of expert radiologists and thoracic oncologists in consensus evaluated completeness, accuracy, and clarity. All the quality indicators were expressed on a 100-point scale. The Wilcoxon signed ranks, and Wilcoxon-Mann Whitney tests were used for statistical analyses. RESULTS: Results showed significantly higher completeness for RCR-SR (90 %) and SIRM-SR (100 %) compared to NSR (70 %) in the second session (all p < 0.001). SIRM-SR demonstrated superior accuracy (70 % vs. 55 %, p < 0.001) over NSR, while RCR-SR and NSR accuracy did not significantly differ (60 % vs. 62.5 %, p = 0.06). In the second session, RCR-SR and SIRM-SR surpassed NSR in completeness, accuracy, and clarity (all p < 0.001, except p = 0.04 for accuracy between RCR-SR and NSR). SIRM-SR outperformed RCR-SR in completeness (100 % vs. 90 %, p < 0.001) and accuracy (70 % vs. 62.5 %, p = 0.002), with equivalent clarity (90 % for both, p = 0.27). CONCLUSIONS: Inexperienced readers using RCR-SR and SIRM-SR demonstrated high-quality reporting, indicating their potential in radiology residency programs to enhance reporting skills for NSCLC staging and effective interaction with all the physicians involved in managing NSCLC patients.

Structured report for chest high-resolution computed tomography in patients with connective tissue disease: Impact on the report quality as perceived by referring clinicians.

RATIONALE AND OBJECTIVES: To evaluate the impact on perceived report quality of referring rheumatologists for a chest high-resolution computed tomography (HRCT) structured report (SR) template for patients with connective tissue disease (CTD), compared to the traditional narrative report (NR). MATERIALS AND METHODS: We retrospectively considered 123 HRCTs in patients with CTD. Three radiologists, blinded to the original NRs they wrote during clinical routine, re-reported each HRCT using an SR dedicated template. We then divided all NR-SR couples into three groups (41 HRCT each). Each group was evaluated by one of three rheumatologists (R1, R2, R3), who expressed their perceived report quality for the respective pools of NRs and SRs in terms of completeness, clarity (both on a 10-points scale), and clinical relevance (on a 5-points scale). The Wilcoxon test and the McNemar test were used for statistical analysis. RESULTS: For each rheumatologist, SR received higher ratings compared to NR for completeness (median ratings: R1, 10 vs. 7; R2, 10 vs. 8; R3, 10 vs. 6, all p < 0.0001), clarity (median ratings: R1, 10 vs. 7; R2, 10 vs. 8; R3, 10 vs. 7, all p < 0.0001), and clinical relevance (median ratings: R1, 5 vs. 4; R2, 5 vs. 4; R3, 5 vs. 1, all p < 0.0001). After rating dichotomization, the use of SR led to a significant increase (p < 0.01) in completeness, clarity, and clinical relevance as compared to NR, except for clarity as perceived by R2 (p = 1). CONCLUSION: Referring rheumatologists' perceived report quality for structured reporting of HRCT in patients with CTD was superior to narrative reporting.

Hyperbilirubinemia after liver transplantation: the role of coupled plasma filtration adsorption.

Hyperbilirubinemia often accompanies liver failure; therefore, artificial liver support devices are currently used as a bridge to more definitive treatments to eliminate water-soluble and albumin-bound toxins. We report 2 patients, of which, after liver transplantation, the first experienced early allograft dysfunction and the other hyperbilirubinemia linked to chronic rejection. After 3 cycles of coupled plasma filtration adsorption (CPFA), the bilirubin promptly decreased in both cases. CPFA is an extracorporeal therapy that uses plasma filtration associated with an adsorbent cartridge and hemofiltration to remove cytokines and inflammatory mediators associated with septic shock, severe sepsis, and multiple organ dysfunction syndrome. Each cycle of treatment lowered the bilirubin of our patients by ∼40%. CPFA deserves attention as a potential inexpensive short-lasting device to treat hyperbilirubinemia after liver surgery or transplantation. Moreover, the effects of CPFA should be further studied to address inflammatory mediators in chronic rejection after liver transplantation or other immunologic disorders.

Polymethylmethacrylate membrane and serum free light chain removal: enhancing adsorption properties.

INTRODUCTION: Polymethylmethacrylate (PMMA) membranes can adsorb a wide variety of uremic toxins including serum free light chains (sFLC). However, limited data are available regarding the clinical use of PMMA in multiple myeloma patients and its maximum adsorption capacity in this setting. AIM: This study aimed to measure the capacity of PMMA to adsorb sFLC and identify strategies to improve its efficiency in clinical practice. METHODS: Ten patients with dialysis-dependent renal failure and high levels of sFLC were included in the study. Five patients received standard PMMA hemodialysis (HD; n = 18), while in the other 5 patients a new technique called enhanced adsorption dialysis (EAD) was used, which involves PMMA dialyzer replacement after 2 h (n = 19). In all patients, sFLC were measured at the beginning and at the end of each dialysis session to calculate the difference between start and end of treatment and the percentage removal. RESULTS: PMMA membranes reduced sFLC in both the PMMA HD and EAD groups. PMMA HD showed similar efficiency on κ and λ percentage removal (22.3 and 21.0%, respectively, n.s.) but, in contrast, had a significantly greater effect on the delta of sFLC in κ [1,555 mg/l (-511 to +6,027)] versus λ [390 mg/l (120-650)] treatments (p = 0.007). EAD treatments only partially increased percentage removal of κ sFLC (22.3-31.0%, p = 0.38), while they had a significantly great effect on λ (21.0-53.1%, p = 0.003). A positive linear correlation was found between delta sFLC and pre-HD sFLC concentrations in PMMA HD κ treatments (r = 0.68, p < 0.02) but not for λ treatments (r = 0.54, p = 0.21), while the analysis of patients receiving EAD demonstrated a strong positive correlation for both κ and λ subtypes (r = 0.81 and r = 0.85, respectively, p < 0.008). In EAD sessions, a positive linear correlation was shown between blood flow during treatment and percentage removal of sFLC (r = 0.58, p = 0.02); however, with PMMA HD such a correlation was not observed (r = 0.28, p = 0.25). CONCLUSIONS: PMMA membranes can efficiently adsorb sFLC, but the process is limited by membrane saturation and is different between κ and λ sFLC. The new EAD technique can greatly improve λ removal but only partially act on κ sFLC. Therefore, EAD should be considered a valid economic treatment option without side effects in particular subsets of patients for the removal of sFLC.

Accuracy of visual analysis vs. apparent diffusion coefficient quantification in differentiating solid benign and malignant focal liver lesions with diffusion-weighted imaging.

PURPOSE: The authors compared the accuracy of diffusion-weighted imaging (DWI) visual analysis (VA) vs. apparent diffusion coefficient quantification (ADC-Q) in assessing malignancy of solid focal liver lesions (FLLs). MATERIALS AND METHODS: Using a 1.5-T system, two radiologists retrospectively assessed as benign or malignant 50 solid FLLs: (a) by VA of signal intensity on DWI images at b=800 s/mm(2) and ADC map; (b) by quantifying lesion ADC. Reference standard included histology or follow-up confirmation of diagnosis by a consensus panel. Receiver operating characteristic (ROC) curve analysis was performed. RESULTS: because of 20 false-negative hepatocellular carcinomas, VA showed lower accuracy than ADC-Q (52.0% VS. 68.0%). however, stratified accuracy for metastases was higher with VA (75.0 VS. 66%). ADC and signal features of malignant and benign FLLs were found to largely overlap. CONCLUSIONS: VA performed worse than ADC-Q for hepatocellular carcinoma and better for metastases. Overall, the accuracy of both methods was limited because of the overlap in visual appearance and ADC values between solid benign and malignant FLLs.

Degree of bile-duct dilatation in liver-transplanted patients with biliary stricture: a magnetic resonance cholangiography-based study.

PURPOSE: This study assessed whether the degree of bile-duct dilatation in liver-transplanted patients is correlated with the time from intervention and the type of underlying biliary stricture. METHODS AND MATERIALS: Fifty-seven 3D magnetic resonance cholangiograms (MRCs) performed on 42 liver-transplanted patients were retrospectively evaluated. Diameter was measured at the level of the extrahepatic bile duct (EBD), right hepatic duct (RHD), left hepatic duct (LHD), anterior and posterior right hepatic ducts (aRHD, pRHD) and left lateral and medial ducts (LLD, LMD). Data were stratified according to the type of biliary stricture (all types, anastomotic, ischaemic-like, mixed) and compared, on a per-examination basis: (a) between two groups based on time from transplantation using a 1-year threshold (nonlongitudinal analysis); (b) among 26 repeated examinations on 11 patients (longitudinal analysis); (c) among different stricture groups. RESULTS: The biliary tree was slightly dilated within 1 year from transplantation (2.9±1.3 to 6.1±3.2 mm). In general, nonlongitudinal analysis showed minimally larger duct size after 1 year (mean +1.4±0.5 mm) despite significant differences at most sites of measurement considering all types of strictures (p<0.01; Mann-Whitney U test). Longitudinal analysis showed diameter increase over time, although without statistically significant differences (p>0.01; Kruskal-Wallis test). No significant difference in bile-duct size was observed when comparing types of stricture (p>0.01; Kruskal-Wallis test). CONCLUSIONS: Biliary dilatation after liver transplantation is mild and develops slowly regardless of the underlying type of stricture, possibly in relation to graft properties. MRC has a potential role as first-line imaging modality for a reliable assessment of biliary dilatation and the presence of a stricture.

White-matter abnormalities in the right posterior hemisphere in generalized anxiety disorder: a diffusion imaging study.

BACKGROUND: Prior imaging studies have shown structural, functional and biochemical impairments in patients with generalized anxiety disorder (GAD), particularly in the right hemisphere. In this study we investigated, for the first time to the best of our knowledge, the white-matter microstructure organization in GAD. METHOD: A total of 12 patients with DSM-IV GAD and 15 matched healthy controls underwent a magnetic resonance imaging session of diffusion weighted imaging, exploring white-matter water molecules by the means of apparent diffusion coefficients (ADCs). Regions of interests were placed in the frontal, parietal, temporal and occipital lobes and in the splenium and genu of the corpus callosum, bilaterally. RESULTS: ADC measures were significantly greater in patients with GAD in the right splenium and right parietal cortex compared with healthy controls (p⩽0.002). No significant correlations between ADCs and age or clinical variables were found. CONCLUSIONS: We provide evidence that GAD is associated with disrupted white-matter coherence of posterior right hemisphere regions, which may partly sustain the impaired cognitive regulation of anxiety. Future diffusion imaging investigations are expected to better elucidate the communication between the parietal cortex and other right hemisphere regions in sustaining the cognitive processing of social and emotional stimuli in patients with GAD.

Impact of magnetic resonance cholangiography in managing liver-transplanted patients: preliminary results of a clinical decision-making study.

PURPOSE: This study was performed to assess the role of magnetic resonance cholangiography (MRC) in the clinical decision-making process of referring physicians when managing liver-transplanted patients. MATERIALS AND METHODS: Over a 6-month period, 21 liver-transplanted patients with a suspected biliary complication were referred for MRC. Referring physicians were asked to prospectively state, before and after MRC, the leading diagnosis; the level of confidence (on a 0-100% scale); the most appropriate diagnostic/therapeutic plan. Data analysis assessed was the diagnostic yield of MRC; the proportion of change in the leading diagnosis; the therapeutic efficacy (i.e. proportion of change in the initial diagnostic/therapeutic plan); the diagnostic thinking efficacy (i.e., gain in diagnostic confidence). Statistical significance was assessed with the Mann-Whitney U test. MRC accuracy was also calculated. RESULTS: Data analysis showed a diagnostic yield of 85.7%; a proportion of change in leading diagnosis of 19.0%; a therapeutic efficacy of 42.8%; a diagnostic thinking efficacy for concordant and discordant leading diagnoses of 18.8% and 78.7%, respectively (p<0.01). MRC accuracy was 92.3%. CONCLUSIONS: MRC significantly increased the diagnostic confidence, irrespective of the concordance between pre- and posttest diagnoses. Moreover, MRC determined a change in patient management in a significant proportion of cases, leading to clinical benefits.

Chest multidetector computed tomography (MDCT) in patients with suspected acute pulmonary embolism: diagnostic yield and proportion of other clinically relevant findings.

PURPOSE: The authors evaluated the diagnostic yield of chest multidetector computed tomography (MDCT) in acute pulmonary embolism (PE) and the proportion of other clinically relevant findings in a large cohort of consecutive inpatients and patients referred from the emergency department (outpatients). MATERIALS AND METHODS: A total of 327 radiological reports of chest MDCT scans performed for suspected acute PE in 327 patients (158 men, 169 women; mean age 69 years, standard deviation 17.33 years; 233 inpatients, 94 outpatients) were retrospectively evaluated and classified into four categories: 1, positive for PE; 2, negative for PE but positive for other findings requiring specific and immediate intervention; 3, completely negative or positive for findings with a potential for significant morbidity requiring specific action on follow-up; 4, indeterminate. The distribution of findings by categories among the entire population and inpatients and outpatients separately was calculated (chi-square test, α=0.05). RESULTS: In the entire population, the diagnostic yield (i.e. proportion of cases classified as category 1) was 20.2% (66/327). Proportions of cases classified as categories 2, 3 and 4 were 27.5% (90/327), 44.3% (145/327) and 7.9% (26/327), respectively. No statistically significant difference was found between inpatients and outpatients (p=0.193). CONCLUSIONS: In patients with suspected acute PE, chest MDCT provides evidence of conditions requiring immediate and specific intervention (i.e. categories 1 and 2) in nearly 50% of cases, without differences between inpatients and outpatients.

Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography.

Post-cholecystectomy syndrome (PCS) is defined as a complex of heterogeneous symptoms, consisting of upper abdominal pain and dyspepsia, which recur and/or persist after cholecystectomy. Nevertheless, this term is inaccurate, as it encompasses biliary and non-biliary disorders, possibly unrelated to cholecystectomy. Biliary manifestations of PCS may occur early in the post-operative period, usually because of incomplete surgery (retained calculi in the cystic duct remnant or in the common bile duct) or operative complications, such as bile duct injury and/or bile leakage. A later onset is commonly caused by inflammatory scarring strictures involving the sphincter of Oddi or the common bile duct, recurrent calculi or biliary dyskinesia. The traditional imaging approach for PCS has involved ultrasound and/or CT followed by direct cholangiography, whereas manometry of the sphincter of Oddi and biliary scintigraphy have been reserved for cases of biliary dyskinesia. Because of its capability to provide non-invasive high-quality visualisation of the biliary tract, magnetic resonance cholangiopancreatography (MRCP) has been advocated as a reliable imaging tool for assessing patients with suspected PCS and for guiding management decisions. This paper illustrates the rationale for using MRCP, together with the main MRCP biliary findings and diagnostic pitfalls.

Impact of clinical data on chest radiography sensitivity in detecting pulmonary abnormalities in immunocompromised patients with suspected pneumonia.

PURPOSE: Chest radiography (CXR) of immunocompromised patients has low sensitivity in the early evaluation of pulmonary abnormalities suspected to be infectious. The purpose of the study was to evaluate whether the knowledge of clinical data improves the diagnostic sensitivity of CXR in the particular setting of immunocompromised patients after hematopoietic stem cell transplantation (HSCT). MATERIALS AND METHODS: Sixty-four CXRs of immunocompromised patients with clinically suspected pneumonia were retrospectively and independently evaluated by two radiologists to assess the presence of radiological signs of pneumonia, before (first reading) and after (second reading) the knowledge of clinical data. A chest computed tomography (CT) performed within 3 days was assumed as the standard of reference. For each reading, sensitivity of both radiologists was calculated. RESULTS: Readers showed a sensitivity of 39% and 58.5% for the first reading, and 43.9% and 41.5% for the second reading, respectively. For both readers, these values were not significantly different from those obtained at first reading (McNemar's test, p>0.05). Interobserver agreement at second reading was fair (Cohen test, k=0.33). CONCLUSIONS: The sensitivity of CXR is too low to consider it a stand-alone technique for the evaluation of immunocompromised patients after HSCT with suspected pneumonia, even if the radiologist knows detailed clinical data. For these patients, an early chest CT evaluation is therefore recommended.

Ultrasonographic analysis in vitro of parietal thickness of lower limb varicose veins.

PURPOSE: The aim of this study was to evaluate the ability of ultrasound (US) to measure the parietal thickness of varicose veins. MATERIALS AND METHODS: In a blind in vitro analysis, 28 great saphenous veins, obtained after stripping surgery from 28 patients with chronic venous insufficiency, were examined with a digital US scanner ATL-HDI5000, linear 5-1 to 2-MHz broadband probe, compound imaging technique and analogic-digital zooming. We obtained one to three progressive measurements for each vein wall (total 67 parietal thicknesses). The samples, fixed in formalin, were sent to the pathology laboratory: sections were obtained at the same level of the sonographic planes, and images were obtained by digital camera mounted on an optical microscope. Measurements obtained at histology were considered as the gold standard. K-statistic was applied to compare sonographic and histologic measurements. RESULTS: Considering only the hypoechoic wall portion, 29/29 (100%) diagnoses of hypotrophy (K=0.91), 19/22 (86%) diagnoses of normotrophy (K=0,47) and 12/16 (75%) diagnoses of hypertrophy (K=0.7) were obtained by sonography. CONCLUSIONS: In our preliminary experience, the in vitro study of varicose veins allows precise, at least morphological, detection of hypotrophic walls. If these preliminary data are confirmed in vivo, sonography could be used to discriminate patients eligible for conservative treatment instead of surgery.

Multidetector CT with double arterial phase and high-iodine-concentration contrast agent in the detection of hepatocellular carcinoma.

PURPOSE: The purpose of this study was to determine whether the double arterial phase with multidetector computed tomography MDCT and high-iodine-concentration contrast material (CM) improves identification of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Fifty patients with 111 HCC foci (61 confirmed histologically, 46 confirmed by percutaneous interventional procedures, four confirmed by CT follow-up of at least 6 months) underwent MDCT with a double arterial phase and a portal venous phase after administration of contrast material with a high iodine concentration (400 mgI/ml, 2 ml/kg, 5 ml/s). Two radiologists independently evaluated the images in three distinct reading sessions (early arterial phase (EAP), late arterial phase (LAP) and double arterial phase) to determine presence, number and degree of suspicion of HCC. The sensitivity and the positive predictive value (PPV) were calculated for every reading session. The following statistical evaluations were used: k statistic and McNemar's test. RESULTS: Mean sensitivity and PPV in the detection of HCC were, respectively, 83.8% and 93.5% for EAP, 90.5% and 94.8% for LAP, and 94.1% and 95.1% for the double arterial phase. Sensitivity of the double arterial phase was statistically higher when compared with EAP alone but showed no statistically significant difference when compared with LAP. The k values ndicated moderate-to-excellent interobserver agreement in all reading sessions. CONCLUSIONS: Sensitivity and PPV increase progressively when passing from EAP to LAP to double-arterial-phase images obtained with contrast material with a high iodine concentration. However, the difference in sensitivity between LAP and the double arterial phase was not statistically significant.

[Calcimimetics]. / I calciomimetici.

Current therapy for secondary hyperparathyroidism in uremia has relatively poor success in achieving the target levels of parathyroid hormone (PTH), calcium and phosphate established by the NKF-K/DOQI guidelines. The discovery and characterization of a new membrane receptor able to sense minimal Ca changes (CaSR) started intensive research in the attempt to characterize better its functions and its finding compounds, which could modulate its activity. CaSR is expressed not only in the cells that secrete calcium-regulating hormones (parathyroid cells and thyroid C-cells) and in cells involved in calcium transport mechanisms (ie intestinal cells, bone-forming osteoblasts, and cells of different nephron segments), but also in other tissues with, as yet, a not completely defined role. CaSR stimulation by the agonists is followed by the activation of a great number of G-proteins mediated intracellular signalling pathways (PLC, PLA, PLD, PKC, PKA, etc). At the level of parathyroid cells, the main effect is the increase in IP3, followed by a mobilization of intracellular Ca stores, which inhibit PTH secretion in a few seconds or minutes. Long-term CaSR stimulation is also able to induce a reduction in both PTH synthesis and parathyroid cell proliferation. More than 100 mutations of the gene coding for CaSR have been described. Some of these mutations are matched by a gain or reduction/loss of function. Notwithstanding, CaSR is widely represented on different tissue cells, the main clinical manifestations of the above genetic changes mainly involve PTH and calcium metabolism. A great number of inorganic and organic cations can interact with the Ca-sensitive N-terminus domain of CaSR, mimicking Ca effects (type I calcimimetics), but these substances have substantial limitations for use in clinical practice. A second class of compounds was produced (NPS R-467, S-467, R-568, S-568, AMG 073), for use in the clinical setting, type II calcimimetics. These compounds, after having interacted with the membrane-spanning domains of the CaSR, induce conformational changes in the N-terminus domain, increasing its affinity for Ca. The preclinical experiences with calcimimetics demonstrated that they were effective in reducing circulating PTH, preventing the progression of secondary hyperparathyroidism, suppressing parathyroid cell proliferation, and reversing osteitis fibrosa at least in animal models. Clinical studies were performed mainly using AMG 073, due to its greater bioavailability and more consistent pharmacokinetic profile. Clinical studies performed in primary hyperparathyroidism proved AMG 073 to be effective in reducing both PTH and Ca serum levels, with a good safety profile. Further studies, mainly focused on the efficacy of AMG 073 in the control of secondary hyperparathyroidism in uremia, confirmed the efficacy of this compound in reducing PTH levels >30% in about 50% of patients. Furthermore, the fall in PTH was matched by a reduction in both calcium and phosphate serum levels of about 5-7%, with a significant reduction in calcium x phosphate product (about 15%). The latter aspect represents a unique pharmacological profile, as compared to all the other available therapeutic means to control secondary hyperparathyroidism in uremia. In addition to their effectiveness, calcimimetics present a relatively safe profile, the only adverse events referred to consist of transient and easily remediable hypocalcemic episodes and some gastrointestinal discomfort symptoms. However, although calcimimetics represent a real advancement in the field of treating secondary hyperparathyroidism in uremic patients, their use should be matched by the awareness that previously the success of a high number of new drugs proposed have been flawed by negative consequences in the long term. Therefore, strict clinical control is necessary in the next few years when the use of these new compounds will widen.

De novo HCV infection among dialysis patients: a prospective study by HCV core antigen ELISA assay.

BACKGROUND: Dialysis patients remain a high-risk group for hepatitis C virus infection. The current diagnosis of hepatitis C virus in dialysis patients includes serological measurement of anti-hepatitis C virus antibody; however, nucleic acid amplification technology for assessing hepatitis C virus viraemia is commonly used in other populations. An enzyme-linked immunosorbent assay test for detecting antibody to hepatitis C nucleocapsid core antigen (hepatitis C virus core antigen) in human serum has been recently developed (hepatitis C virus Core Antigen enzyme-linked immunosorbent assay test). It is conceived for screening of donor blood products to significantly reduce the 'serologic window' occurring before seroconversion during acute hepatitis C virus. AIM AND METHODS: A cohort (n = 72) of patients on maintenance haemodialysis in a single unit in the years 2000-2003 was included. Study patients were tested monthly by hepatitis C virus Core Antigen enzyme-linked immunosorbent assay in a prospective, clinical trial. Routine results obtained by hepatitis C virus Core Antigen enzyme-linked immunosorbent assay test were confirmed by assessing hepatitis C virus viraemia by branched-chain DNA (bDNA) signal amplification assay. RESULTS: De novo hepatitis C virus infection was identified in three patients during the study period; the hepatitis C virus incidence was 1.38% (95% confidence intervals, 1.31-4.09) per year. In each patient, hepatitis C virus core antigen testing allowed the serological identification of acute hepatitis C virus before anti-hepatitis C virus seroconversion. Hepatitis C virus RNA testing confirmed the results obtained by hepatitis C virus Core Antigen enzyme-linked immunosorbent assay in all cases. The time from initial hepatitis C virus detection by hepatitis C virus Core Antigen Assay and anti-hepatitis C virus seroconversion was not greater than four weeks. Two (67%) of three patients with de novo hepatitis C virus acquisition were HBsAg negative; both these patients underwent an initial phase of hepatitis C virus viraemia that was associated with an increase in alanine aminotransferase activity and preceded the seroconversion to anti-hepatitis C virus antibody. Nosocomial transmission of hepatitis C virus between haemodialysis patients was implicated in at least two (67%) of these three patients. CONCLUSIONS: Serological testing for hepatitis C virus core antigen can identify acute hepatitis C virus infection before anti-hepatitis C virus seroconversion. The time from initial hepatitis C virus detection by hepatitis C virus core antigen assay and anti-hepatitis C virus seroconversion was not >4 weeks. De novo acquisition of hepatitis C virus in haemodialysis was associated with a rise in alanine aminotransferase levels. Hepatitis C virus core antigen enzyme-linked immunosorbent assay test results can be obtained in routine laboratories without the need of special equipment or training. Hepatitis C virus core antigen testing among anti-hepatitis C virus negative patients on maintenance dialysis is suggested in order to early assess de novo hepatitis C virus within dialysis units.

Folate measurements in patients on regular hemodialysis treatment.

Patients on regular hemodialysis treatment may develop megaloblastic anemia caused by folate deficiency, but whether folate supplementation is required is still controversial, particularly during erythropoietin administration. Erythrocyte folate concentration is a better indicator of folate status than serum folate, although the latter is the variable generally measured. We measured serum and erythrocyte folate in blood samples from 112 regular hemodialysis patients (57 men, 55 women, 50 treated with erythropoietin, and 62 not) by Stratus Folate immunoenzymatic assay (Dade). Patients with very low serum (<2.87 ng/mL) but normal erythrocyte folate were reinvestigated 4 months later without receiving folate supplementation meanwhile. Serum folate concentrations were 0.48 to 12.76 ng/mL (median, 3.40) and erythrocyte folate 0.19 to 1.85 microg/mL (median, 0.42). Only 37% serum folate values were in the relevant reference interval compared with 80.2% erythrocyte folate values (3.08 to 17.65 ng/mL and 0.24 to 0.64 microg/mL, respectively). A significant correlation was found between serum and erythrocyte folate concentrations, without clinical relevance caused by the wide scatter around the regression line. Serum and erythrocyte folate did not vary significantly between patients given erythropoietin and those not so treated. The folate status of the 24 patients with very low serum folate was almost unchanged 4 months later. According to the serum folate test, 63% of patients needed folate supplementation, whereas the erythrocyte folate test, a better indicator of folate status, suggested that only 1.8% of patients needed folate supplementation. Erythropoietin therapy appears not to be an indication for standard folate supplementation in hemodialysis patients.

Hepatitis G virus infection in hemodialysis patients.

The increased risk of hemodialysis patients for infections sustained by hepatitis viruses is likely to extend to a newly discovered parenterally transmitted virus, HGBV-C/HGV, able to cause acute and chronic hepatitis. The aim of this study was to assess the prevalence and clinical relevance of this infection in Italian hemodialysis patients. Nineteen of 100 patients (19%) on maintenance hemodialysis were viremic for HGBV-C/HGV, and all of them were infected with a HGV-like genotype. Eight of these patients were coinfected by hepatitis B or hepatitis C viruses. A clinical picture of chronic hepatitis was not appreciable in patients with isolated HGV infection and the presence of HGV did not appear to modify the clinical course of hepatitis B and hepatitis C infections.

Renal effects of dietary supplementation with fish oil in cyclosporine-treated liver transplant recipients.

Nephrotoxicity is the main untoward effect of cyclosporine (CsA) treatment. Experimental and clinical data suggest that dietary supplementation with fish oil may lessen cyclosporine nephrotoxicity, possibly by lowering renal thromboxane (Tx) production. We have studied the renal effects of a daily supplementation for 2 months of 12 g fish oil (18% C20:5 n-3 eicosapentaenoic acid [EPA] and 12% C22:6 n-3 docosahexanoic acid [DHA]) in a placebo-controlled (12 g corn oil), prospective, randomized, double-blind study of stable CsA-treated liver transplant recipients. Thirteen patients ingested corn oil capsules and 13 fish oil. Compliance with dietary regimen was confirmed by fatty acid chromatography that showed increased plasma concentrations of EPA (from 0.4 +/- 0.02% to 4.6 +/- 0.5%, P < .0001) and DHA (from 1.8 +/- 0.2% to 3.9 +/- 0.1%, P < .0001) in the fish oil group and increased plasma concentration of linoleic acid (C18:2 n-6) in the corn oil group (from 25 +/- 2% to 28.4 +/- 2%, P < .001). At the end of the 2 months of the study, in the fish oil group the effective renal plasma flow increased by 22% (P = .012), the glomerular filtration rate increased by 33% (P = .057), the renal blood flow increased by 17% (P = .024), and the calculated total renal vascular resistances decreased by 20% (P = .034). In contrast, none of these parameters changed in the corn oil group. The renal functional reserve determined during L-arginine infusion, plasma renin activity (PRA), and plasma aldosterone (PA) remained unchanged during the study in either group.(ABSTRACT TRUNCATED AT 250 WORDS)