[Emphysematous cystitis: Report of one case]. / La cystite emphysémateuse : à propos d'un cas.

INTRODUCTION: Emphysematous cystitis is a rare urinary tract infection characterized by gas in the bladder wall and lumen. CASE REPORT: We report a 92-year-old women admitted with confusion and abdominal pain without fever. Her past medical history included diabetes, urinary incontinence, high blood pressure and mild cognitive impairment. A computed tomography scan (CT scan) revealed emphysematous cystitis. The patient completely recovered within ten days. The main characteristics and the treatment of this uncommon disorder are presented. CONCLUSION: Clinicians should be aware of this diagnosis: early management is essential to reduce morbidity and mortality.

Impact of wastewater treatment plants on receiving surface waters and a tentative risk evaluation: the case of estrogens and beta blockers.

Five estrogenic hormones (unconjugated + conjugated fractions) and 10 beta blockers were analyzed in three wastewater treatment plant (WWTP) effluents and receiving river waters in the area of Lyon, France. In the different samples, only two estrogens were quantified: estrone and estriol. Some beta blockers, such as atenolol, acebutolol, and sotalol, were almost always quantified, but others, e.g., betaxolol, nadolol, and oxprenolol were rarely quantified. Concentrations measured in river waters were in the nanogram per liter range for estrogens and between 0.3 and 210 ng/L for beta blockers depending on the substance and the distance from the WWTP outfall. The impact of the WWTP on the receiving rivers was studied and showed a clear increase in concentrations near the WWTP outfall. For estrogens, the persistence in surface waters was not evaluated given the low concentrations levels (around 1 ng/L). For beta blockers, concentrations measured downstream of the WWTP outfall were up to 16 times higher than those measured upstream. Also, the persistence of metoprolol, nadolol, and propranolol was noted even 2 km downstream of the WWTP outfall. The comparison of beta blocker fingerprints in the samples collected in effluent and in the river also showed the impact of WWTP outfall on surface waters. Finally, a tentative environmental risk evaluation was performed on 15 sites by calculating the ratio of receiving water concentrations to predicted non-effect concentrations (PNEC). For estrogens, a total PNEC of 5 ng/L was considered and these substances were not linked to any potential environmental risk (only one site showed an environmental risk ratio above 1). Unfortunately, few PNECs are available and risk evaluation was only possible for 4 of the 10 beta blockers studied: acebutolol, atenolol, metoprolol, and propranolol. Only propranolol presented a ratio near or above 1, showing a possible environmental risk for 4 receiving waters out of 15.

A prospective observational study of patient training in use of the autohaler inhaler device: the Sirocco study.

BACKGROUND: Asthma guidelines recommend that patients receive inhaler technique training, with rechecks at each visit. However, suboptimal inhaler technique is common. METHODS: This prospective observational study evaluated patient training in use of the Autohaler, a breath-actuated metered-dose inhaler. Physicians enrolled the first four consecutive, eligible adult patients receiving inhaled corticosteroid therapy for asthma. Patients demonstrated their inhaler technique after seeing a demonstration of proper technique and again after physicians gave verbal instruction addressing individual difficulties in technique. Their first and last attempts were evaluated using a 12-item checklist comprising 7 consecutive steps for correct inhaler use and 5 potential errors in device handling or inhalation manoeuvre. RESULTS: A total of 1723 physicians (91% general practitioners) enrolled 6512 patients (mean age 43 years, 52% male). On their first attempt, 2561/6387 (40.1%) of patients were able to complete all procedural steps correctly and without error. A poor inhalation manoeuvre was the most common cause of failure in technique. After education, 91.4% of patients were able to complete all procedural steps correctly and without error. Training session median length was 4 minutes (range 0-45 minutes). CONCLUSIONS: Practical training, coupled with demonstration of inhaler use and observation of technique by a physician, can help patients to improve their inhaler technique and appears feasible in every day practice. Further work is needed to evaluate whether patients maintain good inhaler technique and whether physicians continue the training sessions in everyday practice.

Odors as triggering and worsening factors for migraine in men / Odores como fatores desencadeantes e de piora na enxaqueca de homens

OBJECTIVE: To assess the role of odors in triggering or worsening migraine in men. METHOD: Ninety-eight male migraineurs from the general population were assessed individually through questionnaires. Environmental factors relating to their migraine were reported, with special focus on the role of odors. RESULTS: Odors were the second most frequent triggering factor for migraine attacks (48 percent), behind stressful situations (59 percent). Likewise, odors were the second most frequent worsening factor (73 percent), just behind excessive light (74 percent). Thirty-three individuals (33.4 percent) stated that odors were both triggering and worsening factors for their migraine attacks. Perfume, cigarette smoke and cleaning products were the most frequent migraine-related odors reported by these male migraineurs. CONCLUSION: This was the first study to assess the role of odors in migraine exclusively in men. There was a high degree of odor-related migraine among these men, thus suggesting that patient education could alert such individuals to gender-related factors, since different triggering and worsening factors have been reported by males and females.

OBJETIVO: Avaliar o papel dos odores como fatores desencadeantes e de piora da enxaqueca em homens. MÉTODO: Noventa e oito homens com enxaqueca na população geral foram avaliados individualmente por questionários. Os fatores ambientais relacionados à enxaqueca foram relatados, com foco especial no papel dos odores. RESULTADOS: Os odores foram o segundo fator mais frequente no desencadeamento de crise de enxaqueca (48 por cento), atrás das situações de estresse (59 por cento). Da mesma forma, os odores foram a segunda causa mais frequente de piora das crises (73 por cento), apenas atrás do excesso de luminosidade (74 por cento). Trinta e três indivíduos (33,4 por cento) relataram que os odores eram tanto fatores desencadeantes quanto fatores de piora de suas crises de enxaqueca. Perfume, fumaça de cigarro e produtos de limpeza foram os odores mais relatados como sendo relacionados a enxaqueca pelos homens. CONCLUSÃO: Este foi o primeiro estudo que avaliou o papel dos odores exclusivamente em homens com enxaqueca. Houve um alto índice de enxaqueca relacionada a odores, sugerindo que a educação dos pacientes poderia alertar fatores dependentes do gênero do paciente, uma vez que diferentes fatores desencadeantes e de piora das crises tem sido relatados por homens e mulheres.

Occurrence and removal of estrogens and beta blockers by various processes in wastewater treatment plants.

This study aims at evaluating occurrence and treatment efficiency of five estrogenic hormones and ten beta blockers in wastewater treatment plants (WWTP). The use of consistent sampling procedures, analytical techniques and data processing enabled to achieve an accurate comparison of the performances of the different treatment processes. First, the occurrence of molecules was evaluated in fourteen rural and urban WWTP located in France. Free and total estrogens were analyzed showing that more than 84% of estrogens in the dissolved phase of influent samples are in the free form. In effluent samples, comparable mean values but higher variation are underlined (RSD from 13 to 54% depending on the estrogen, compared to 11-21% for influents). Most of the target molecules are quantified in 30 influent and 31 effluent samples. Similar occurrence frequencies are obtained for influents from rural (6 WWTP) and urban areas (8 WWTP), except for betaxolol which is only quantified in urban wastewaters. Removal efficiencies of 8 biological treatments were studied: suspended growth biomass (activated sludge) and attached growth systems (biofilter, rotating biological contactor, reed-bed filter, trickling filter). Biological treatments are efficient to remove estrogens from the dissolved phase, with removal rate around 90%. For beta blockers, acebutolol and nadolol are efficiently removed (mean removal rate of 80%), whereas sotalol and propranolol are hardly impacted by biological treatments (removal rate below 20%). Finally, 9 tertiary treatment processes were evaluated. Ozonation, reverse osmosis and activated carbon filtration prove a high removal efficiency for beta blockers (above 80%). On the contrary, high speed chemical settler, sand filtration, silex filtration, microfiltration and UV present generally removal rates below 30% for all beta blockers. The polishing pond studied presents variable removal performances depending on the molecules (up to 75% for propranolol). The role of the hydraulic retention time on the removal efficiencies is confirmed.

Improved asthma control with breath-actuated pressurized metered dose inhaler (pMDI): the SYSTER survey.

BACKGROUND AND OBJECTIVES: Poor inhalation technique may impact both asthma control and compliance in patients with asthma. The SYSTER survey is therefore aimed at assessing the influence of starting or switching an existing therapy to a breath-actuated pressurized metered dose inhaler (pMDI, Autohaler) on these parameters. MATERIALS AND METHODS: 709 French general practitioners (GP) enrolled 2588 asthmatic patients in whom therapy with the breath-actuated pMDI was either initiated, or a switch from an existing inhalation device to the said inhaler was deemed necessary. Asthma control was assessed at inclusion and after 4 weeks of treatment with the Juniper Asthma Control Questionnaire (ACQ). In addition, patient adherence was estimated according to the self-reported Morisky scale. RESULTS: 1510 patients (mean age 39 years, standard deviation 18 years; 53% male) completed follow-up after 4 weeks. The main reasons for inhaler change were poor asthma control (49%) and poor coordination (40%). After 4 weeks of therapy with the breath-actuated pMDI, asthma control significantly improved from 2.35 +/- 1.05 to 1.32 +/- 0.93 in the ACQ (p < 0.0001). Also, self-reported patient adherence improved from 2.11 +/- 1.43 to 1.57 +/- 1.53 on the Morisky scale (p < 0.0001). DISCUSSION: These results suggest that by focusing on the inhalation devices, asthma control and compliance with treatment are improved.

[Cushing's syndrome induced by combined treatment with inhaled fluticasone and oral ritonavir]. / Syndrome de Cushing induit par la prise concomitante de fluticasone et de ritonavir.

INTRODUCTION: Fluticasone is a corticosteroid drug which is used in inhaled and nasal formulations for the treatment of asthma and allergic rhinitis. It is metabolized in the liver by the cytochrome P450. Ritonavir, an inhibitor of the HIV protease, also acts as an inhibitor of several isoenzymes of the P450 cytochrome. This property explains the many drug interactions observed with this agent. CASE REPORT: We report two cases of Cushing's syndrome with adrenal insufficiency associated with the combined administration of oral low dose ritonavir and moderate to high dose inhaled fluticasone. CONCLUSION: These observations highlight the fact that the combined administration of fluticasone and ritonavir must be avoided as well as the combined administration of fluticasone and other inhibitors of the cytochrome P450.

[Assessment of asthma control: an audit of clinical practice]. / Evaluation du contrôle de l'asthme: audit de pratique clinique.

INTRODUCTION: Despite the development of international guidelines for the management of asthma, epidemiological surveys suggest that control of the disease remains poor. In order to investigate clinical practice a postal questionnaire was used to study the evaluation of asthma control, the assessment of factors associated with poor control and the impact of tools to measure asthma control. METHODS: 12,000 questionnaires were mailed to 10,000 general practitioners (GP) and 2000 French specialists. RESULTS: The response rate was 13 and 31% for GP and specialists respectively. 44% of specialists and 9% of GP's declared that they made a systematic assessment of nocturnal symptoms, beta2 agonist usage and peak flow. 32% of the specialists and 15% of the GP's declared a systematic search for poor compliance, inhaler technique and the avoidance of trigger factors. 77% of the GP's and 43% of the specialists had never used a questionnaire for asthma control. CONCLUSION: Available tools for the systematic evaluation of asthma control are rarely used and both asthma control itself and factors known to be associated with it are insufficiently monitored. The impact of the implementation in the medical community of a more systematic and pragmatic approach should be evaluated.

[Hypodermoclysis: benefits and indications in geriatrics]. / L'hypodermoclyse: intérêts et indications en gériatrie.

PURPOSE: Older people are at high risk of dehydration. Oral intakes are often inadequate routinely. Intravenous infusion may be difficult in these patients and harmful. Subcutaneous infusion or hypodermoclysis is a useful technique for the cure of a moderate dehydration in elderly patients and especially for its prevention. Moreover, this technique is of great interest in end-life patients. CURRENT KNOWLEDGE AND KEY POINTS: When it is used correctly and when its contraindications are respected (emergency situations), hypodermoclysis is a simple, safe, sure, effective and comfortable technique. It does not need trained supervision and can be used both in an institution and at home, thus avoiding hospitalization of older subjects and reducing health costs. This technique has considerable benefits both psychologically and financially. FUTURE PROSPECTS AND PROJECTS: The numerous advantages of hypodermoclysis should encourage its wider use in older patients at home as well as in institutions. Moreover, new indications need to be evaluated. In this way, subcutaneous infusion of therapeutics or prevention of protein-energy malnutrition by hypodermoclysis of amino acids need further investigations.

Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability.

This study assessed whether the improper use of pressurized metered-dose inhalers (pMDIs) is associated with decreased asthma control in asthmatics treated by inhaled corticosteroids (ICS). General practitioners (GPs) included consecutive asthmatic outpatients treated by pMDI-administered ICS and on-demand, short-acting beta2-agonists. They measured an asthma instability score (AIS) based on daytime and nocturnal symptoms, exercise-induced dyspnoea, beta2-agonist usage, emergency-care visits and global perception of asthma control within the preceding month; the inhalation technique of the patient also was assessed. GPs (n=915) included 4,078 adult asthmatics; 3,955 questionnaires were evaluable. pMDI was misused by 71% of patients, of which 47% was due to poor coordination. Asthma was less stable in pMDI misusers than in good users (AIS: 3.93 versus 2.86, p<0.001). Among misusers, asthma was less stable in poor coordinators (AIS: 4.38 versus 3.56 in good coordinators, p<0.001). To conclude, misuse of pressurized metered-dose inhalers, which is mainly due to poor coordination, is frequent and associated with poorer asthma control in inhaled corticosteroid-treated asthmatics. This study highlights the importance of evaluating inhalation technique and providing appropriate education in all patients, especially before increasing inhaled corticosteroid dosage or adding other agents. The use of devices which alleviate coordination problems should be reinforced in pressurized metered-dose inhaler misusers.

Excessive alcohol consumption favours high risk polyp or colorectal cancer occurrence among patients with adenomas: a case control study.

BACKGROUND AND AIMS: Excessive alcohol consumption is a risk factor for developing colorectal adenomas. This study aimed to investigate the influence of excessive alcohol consumption on the occurrence of high risk polyps (adenoma > or = 10 mm, villous component, high grade dysplasia) or colorectal cancer among patients with at least one colonic adenoma. PATIENTS AND METHODS: Three groups of patients with at least one colorectal adenoma were included in a case control study: 401 heavy drinkers (group HD, mean daily alcohol intake 117 (SD 4) g/day for a mean duration of 22 (SD 0.6) years), aged 57 (0.5) years (78% men); 152 patients suffering from irritable bowel syndrome (IBS), aged 61 (0.9) years (57% male); and 108 patients with a family history (FH) of colorectal adenoma or cancer, aged 55 (1) years (64% male). Exclusion criteria were: anaemia, haematochezia, personal history of colorectal adenoma or cancer, and for groups HD and IBS a family history of colorectal adenoma and/or cancer. Relative risks were estimated by the odds ratio (OR) using a logistic regression model and were expressed with 95% confidence interval (CI). RESULTS: After age and sex adjustment, the likelihood of having an adenoma > or = 10 mm was higher in group HD than in the IBS group (OR 1.8, 95% CI (1.2-2.7)) and the likelihood of having high risk adenomas or cancer was higher in group HD compared with the IBS group (OR 1.6, 95% CI (1.2-2.1)) and the FH group although this was not significant (OR 1.6, 95% CI (0.97-2.6) (p=0.081); 90% CI (1.03-2.4)). After age and sex adjustment, the likelihood of having an adenoma with high grade dysplasia or cancer was higher in group HD than in the IBS group (OR 1.7, 95% CI (1.02-2.8)) or group FH, although this was not significant (OR 3.7, 95% CI (0.98-15) (p=0.076); 90% CI (1.10-12.47)). CONCLUSION: In patients with at least one colorectal adenoma, excessive alcohol consumption increases the likelihood of developing high risk adenomas or colorectal cancer.

[Patients with alcoholic liver disease hospitalized in gastroenterology. A national multicenter study]. / Maladies alcooliques du foie hospitalisées en Hépato-Gastroentérologie. Enquête multicentrique nationale.

OBJECTIVES: To describe the characteristics of in-patients with alcoholic liver disease in Hepatogastroenterology and to evaluate whether geographic location was a risk factor for cirrhosis. METHODS: A French, national, multicenter, prospective investigation was performed in the last quarter of 1997. To be included in the study, patients had to have drunk at least 50 g of alcohol per day for the past year or to have cirrhosis. RESULTS: Seventeen centers included 802 patients, 20% had histologically proven cirrhosis or probable cirrhosis. Thirty-five percent had undergone liver biopsy. Twenty five percent of these patients had cirrhosis without acute alcoholic hepatitis and 37% had cirrhosis with acute alcoholic hepatitis. After dividing France along a Bordeaux-Strasbourg axis, there was more histologically proven or probable cirrhosis in the North (46%) than in the South (36%) (P<0.005) while daily alcohol intake was greater the South (150 +/- 6 g) than in the North (129 +/- 4 g) (P<0.0001). When the six variables (age, sex, daily consumption of alcohol over the past 5 years, presence of hepatitis B surface antigen and antibodies to hepatitis C virus, total duration of alcohol abuse) were considered together in stepwise logistic regression analysis, geographic location changed the prediction of cirrhosis. The odds ratio for cirrhosis in patients living to the North of the Bordeaux-Strasbourg axis was 1.9 (95% confidence interval range 1.1-3.2) (P<0.02), suggesting the role of nutritional factors.

Abnormal von Willebrand factor in bleeding angiodysplasias of the digestive tract.

BACKGROUND & AIMS: Involvement of an abnormal von Willebrand factor in the bleeding expression of gastrointestinal angiodysplasias has been suggested but not assessed by prospective studies. METHODS: To address this issue, 27 patients with either nonbleeding (group A, n = 9) or bleeding (group B, n = 9) digestive angiodysplasias or telangiectasias or diverticular hemorrhage (group C, n = 9) were enrolled. In all patients, an analysis of von Willebrand factor and a screening for the most common disorders associated with an acquired von Willebrand disease were performed. RESULTS: In all patients from groups A and C, von Willebrand factor was normal, and no underlying disease could be found. In contrast, all but 1 patient from group B had a variable selective loss of the largest multimeric forms of von Willebrand factor, associated in 7 cases with a stenosis of the aortic valve. CONCLUSIONS: This study indicates that most patients with bleeding angiodysplasia or telangiectasia have a deficiency of the largest multimers of von Willebrand factor induced by a latent acquired von Willebrand disease. Because these multimers are the most effective in promoting primary hemostasis at the very high shear conditions related to these vascular malformations, we suggest that their deficiency is likely to contribute to the bleeding diathesis.

Tumor necrosis factor soluble receptor p55 and lipid peroxidation in patients with acute alcoholic hepatitis.

OBJECTIVES: In experimental models, liver injury induced by ethanol, cytotoxic activity of tumor necrosis factor (TNF) -alpha is principally mediated by TNF receptor p55 (TNFRp55). Among the various mechanisms underlying the toxic effects of TNF-alpha, overproduction of reactive oxygen species seems to play a key role in mediating TNF-alpha-induced cytotoxicity. The aim of this study was to evaluate, in patients with alcoholic liver disease, whether alcohol TNFRp55-mediated hepatotoxicity could account for lipid peroxidation expressed by significant increase in serum thiobarbituric reactive acid substances (TBARS) content, and could be amplified by decrease in blood total glutathione content and decrease in plasma antioxidant protective capacity. METHODS: We studied 27 patients with histological alcoholic liver disease (five fibrosis, six acute alcoholic hepatitis (AAH) without cirrhosis, four cirrhosis without AAH, and 12 cirrhosis with AAH. TNFsRp55 and TNFsRp75 plasma levels were measured using ELISA assays. Plasma lipid peroxidation was evaluated by the content of TBARS. Total glutathione (tGSH) content in blood was determined by a kinetic assay. The sensitivity of erythrocytes to an oxidative stress and the plasma antioxidant protective capacity were simultaneously determined by a simple method. RESULTS: In the 18 patients with mild or severe AAH, the plasma levels of TNFsRp55 were negatively correlated with tGSH and were positively correlated with TBARS, with total bilirubin and with discriminant function. tGSH was positively correlated with plasma selenium. The plasma levels of TNFsRp75 were positively correlated with TBARS and with total bilirubin. There was no significant correlation with the mean inhibitory 50% plasma volume or with the percentage of hemolyzed erythrocytes. CONCLUSIONS: Our data support the notions that, in patients with AAH, TNFsRp55 probably mediates cytotoxicity of TNF-alpha, and that cytotoxic effect could be amplified by tGSH depletion in enhancing lipid peroxidation.

Laparoscopic cystogastrostomy for pancreatic pseudocyst is safe and effective.

Between March 1997 and March 1998, three consecutive patients underwent laparoscopic cystogastrostomy for persistent giant retrogastric pancreatic pseudocyst complicating an attack of acute pancreatitis. The mean cyst diameter was 15 +/- 1 cm (range 14-16). The procedure was performed with four trocars. The anterior wall of the stomach was opened longitudinally. The pseudocyst was entered through the posterior wall of the stomach. A cystogastrostomy was created by suturing the margins of the communication by interrupted nonabsorbable sutures. The mean operative time was 123 +/- 15 min, and there were no postoperative complications. The mean postoperative hospital stay was 4 +/- 1 days. Computed tomography demonstrated complete resolution of the pseudocyst. Laparoscopic cystogastrostomy represents a good therapeutic option for persistent retrogastric pancreatic pseudocyst.

Prothrombin 20210G/A mutation in two patients with mesenteric ischemia.

Primary cases of splanchnic vein thrombosis are now less common since a systematic screening for hypercoagulability is performed. In 1996, a sequence variation in the 3'-untranslated region of the prothrombin gene (F.II 20210G/A mutation) has been linked to a threefold increased risk for venous thrombosis. The role of this thrombophilic disorder is not documented in patients with thrombosis of the splanchnic veins. This report presents two patients with a mesenteric ischemia associated with a heterozygous state for the F.II 20210G/A mutation. The first patient developed an ischemic colitis and the second one an ischemic necrosis of the terminal ileum related to a thrombosis of the superior mesenteric vein. In both cases, another thrombotic risk factor was associated: either a general prothrombic state (primary antiphospholipid syndrome) or a focal factor (abnormal hemodynamic conditions related to a liver cirrhosis). It has recently been proposed that several conditions need to be combined for deep vein thrombosis to develop. Screening for the combination of multiple underlying prothrombotic conditions thus appears justified in patients with splanchnic thrombosis. The role of the F.II 20210G/A mutation as a predisposing factor for thrombosis of the digestive vessels should be considered and needs further investigation.

[Descriptive epidemiology of patients with alcoholic liver disease hospitalized in a hepato-gastroenterology service]. / Analyse descriptive des malades ayant une maladie alcoolique du foie hospitalisés dans un service d'Hépato-Gastroentérologie.

OBJECTIVE: To improve the detection of early stage alcoholic liver disease and to identify the importance of this disease, this study compared epidemiological characteristics, the reasons for and the duration of hospitalization, in-patient mortality and the frequency of multiple hospitalizations in alcoholic patients without cirrhosis and in patients with alcoholic cirrhosis hospitalized in the hepatogastroenterology department of Antoine-Beclere Hospital. MATERIAL AND METHODS: From January 1982 to December 1995, all patients with a daily alcohol intake in the previous year of at least 50 g per day and all patients with alcoholic cirrhosis whatever their drinking habits were studied. RESULTS: Three thousand three hundred and forty six patients were included. The daily alcohol intake in the previous five years was 118 +/- 81 g and the duration of alcohol abuse was 22 +/- 13 years. Two thousand one hundred eight patients had liver biopsy; 37% had histologically proven or probable cirrhosis. Forty one percent of the patients without cirrhosis who had liver biopsy already had steatofibrosis and/or acute alcoholic hepatitis. 32.5% of the patients had hepatitis B virus markers. 7.7% of the patients were positive for anti hepatitis C virus antibody. Thirty two percent of the patients with cirrhosis were women versus 22% of the patients without cirrhosis (P < 0.01). Alcoholism was the reason for the first hospitalization in sixty percent of the patients without cirrhosis and in twenty percent of the patients with cirrhosis (P < 0.01). On the other hand, ascites were the first reason for the first hospitalization in patients with cirrhosis (28%). The two main causes for multiple hospitalizations were also ascites and alcoholism. CONCLUSION: Two thirds of heavy drinkers did not have cirrhosis on admission since alcoholism was the first reason for multiple hospitalizations in these patients, therefore the management of alcoholism in out-patients must be improved.

[Biological diagnosis of the type of liver disease in alcoholic patients with abnormal liver function tests]. / Diagnostic biologique du type d'hépatopathie chez des malades alcooliques ayant des tests biologiques hépatiques anormaux.

OBJECTIVES: The histological diagnosis of the different stages of alcoholic liver disease is not systematic. The aim of this study was to assess whether common biological features were useful in identifying the different stages. METHODS: One thousand twenty six alcoholic patients with liver histology and without any associated diseases or infections likely to alter serum liver tests were studied. Diagnostic analyses were performed using stepwise discriminant analysis in the entire population and in asymptomatic patients. RESULTS: a) Serum ASAT activity levels were only normal in 39% of the patients with normal histological liver and in 14% of the patients with steatosis; b) liver failure was already present in patients with fibrosis without cirrhosis; c) betagamma block was the only biochemical parameter which confirmed the diagnosis of cirrhosis without biopsy; d) the diagnostic accuracy of common tests was weak for the diagnosis of alcoholic liver disease without cirrhosis but prothrombin time could be useful in excluding the diagnosis of cirrhosis with and without acute alcoholic hepatitis when liver biopsy is not available. CONCLUSION: Only a prothrombin time of 80% with a negative predictive value of 94% and the presence of beta-gamma [corrected] block with a positive predictive value of 98% were useful for assessing the diagnosis of cirrhosis in all patients with alcoholic liver disease.

A particularly aggressive combined glucagonoma and gastrinoma syndrome.

Duodeno-pancreatic biochemically polyfunctional endocrine tumour is a well known entity. Usually, only one hormone is responsible for the clinical features. We report a case of aggressive combined glucagonoma and gastrinoma tumour without metastases, causing respectively diabetic ketoacidosis and fulminant peptic ulcer, and death. Occasional patients can present with clinical features of both glucagonoma and gastrinoma. Diabetic patients exhibiting migratory skin lesions should be suspected of glucagonoma. In addition, a multidisciplinary approach to such patients including dermatologists, surgeons, radiologists and endoscopists is mandatory.