Metabolic syndrome in patients with coeliac disease on a gluten-free diet.

BACKGROUND: Several studies have shown that weight changes are common in patients with coeliac disease after starting a gluten-free diet (GFD), but data on the prevalence of metabolic syndrome in this population are still scarce. AIMS: To assess the prevalence of metabolic syndrome in patients with CD at diagnosis and 1 year after starting GFD. METHODS: We enrolled all consecutive patients with newly diagnosed coeliac disease (CD) who were referred to our third-level CD Unit. For all patients we collected: waist circumference, BMI, blood pressure, lipid profile (HDL cholesterol, triglycerides) and levels of blood glucose. Diagnosis of metabolic syndrome was made according to the International Diabetes Federation (IDF) criteria for European countries. The prevalence of metabolic syndrome was re-assessed after 12 months of GFD. RESULTS: Ninety-eight patients with CD were assessed, two patients with CD (2%) fulfilled the diagnostic criteria for metabolic syndrome at diagnosis and 29 patients (29.5%) after 12 months of GFD (P < 0.01; OR: 20). With regard to metabolic syndrome sub-categories 1 year after GFD compared to baseline respectively: 72 vs. 48 patients exceeded waist circumference cut-off (P < 0.01; OR: 2.8); 18 vs. 4 patients had high blood pressure (P < 0.01; OR: 5.2); 25 vs. 7 patients exceeded glycemic threshold (P = 0.01; OR: 4.4); 34 vs. 32 patients with CD had reduced levels of HDL cholesterol (P = 0.7); and 16 vs. 7 patients had high levels of triglycerides (P = 0.05). CONCLUSIONS: Patients with coeliac disease show a high risk of metabolic syndrome 1 year after starting a gluten-free diet. We suggest that an in-depth nutritional assessment is undertaken for all patients with coeliac disease.

The presence of anti-endomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy.

BACKGROUND: The new ESPGHAN guidelines for diagnosis of paediatric coeliac disease suggest to avoid biopsy in genetically pre-disposed and symptomatic individuals with positive anti-endomysial antibodies (EMA) and anti-tissue transglutaminases (a-tTG). However, duodenal biopsy remains the gold standard in adult coeliac disease. AIMS: To establish the cut-off values of a-tTG, which would: predict the presence of duodenal histology (Marsh ≥2) diagnostic for coeliac disease; and predict the presence of villous atrophy (Marsh 3) in adults. METHODS: We performed an observational prospective study including all consecutive adult patients with suspected coeliac disease. All subjects were tested for EMA and a-tTG. Coeliac disease diagnosis was made in presence of Marsh ≥2, a-tTG >7 U/mL and positive EMA. A ROC curve was constructed to establish the best specificity cut-off of a-tTG levels, which would predict the presence of Marsh ≥2 and Marsh 3 at histology. RESULTS: The study included 310 patients with positive antibodies. Histology showed Marsh 1 in 8.7%, Marsh 2 in 3.5%, Marsh 3 in 87.7%. The best cut-off value of a-tTG for predicting Marsh ≥2 was 45 U/mL (sensitivity 70%; specificity 100%; PPV 100%; NPV 24.1%); the best cut-off for predicting villous atrophy was 62.4 U/mL (sensitivity 69%, specificity 100%; PPV 100%; NPV 31%). CONCLUSIONS: The diagnosis of coeliac disease can be reached without histology in adult patients with positive EMA and a-tTG levels >45 U/mL. An a-tTG level >62.4 was diagnostic for villous atrophy. These results could contribute to improving the diagnosis of coeliac disease by allowing for a significant reduction in diagnosis-related costs.

Role of gluten intake at the time of hepatitis B virus vaccination in the immune response of celiac patients.

Some reports have demonstrated an inadequate response to hepatitis B vaccination in patients affected by celiac disease. The aim of our study was to evaluate hepatitis B vaccination response in relation to gluten exposure status in patients with celiac disease. To measure the gluten exposure status at the time of vaccination, we considered three groups: group A (exposed to gluten), including patients vaccinated as 12-year-old adolescents (the celiac disease diagnosis was established after vaccination); group B (not exposed to gluten), including patients vaccinated as 12-year-old adolescents on a gluten-free diet at the time of vaccination; and group C (infants), including patients vaccinated at birth. The response of celiac patients to hepatitis B vaccination was compared to that of healthy subjects, i.e., those in the control group (group D). This study included 163 celiac patients (group A, 57 patients; group B, 46 patients; and group C, 60 patients) and 48 controls (group D). An inadequate response to hepatitis B immunization was present in 43.9% of patients in group A, 34.8% of patients in group B, 58.3% of patients in group C, and 8.3% of patients in group D (group A versus group D, P < 0.001; group B versus group D, P = 0.002; group C versus group D, P = 0.001) (no significant difference for group A versus group B and group A versus group C was evident). Our data suggest that gluten exposure does not influence the response to hepatitis B immunization and that the human leukocyte antigen probably plays the main immunological role in poor responses to hepatitis B-vaccinated celiac patients.

Effect of beta-glucan, inositol and digestive enzymes in GI symptoms of patients with IBS.

BACKGROUND: Irritable bowel syndrome (IBS) is a very common functional gastrointestinal (GI). Diagnosis of IBS is based on the fulfilment of the Rome III criteria. Common GI symptoms are lower abdominal pain, bloating and disturbed defecation, such as urgent diarrhoea and/or episodes of chronic constipation. Many agents have been employed in the management of IBS, although only few have been demonstrated to show a relevant efficacy. AIM: To evaluate the effectiveness of the administration of a mixture of beta-glucan, inositol and digestive enzymes (Biointo) in improving GI symptoms in patients affected by IBS. PATIENTS AND METHODS: 50 IBS patients (20 males, 30 females; mean age 51 +/- 19) were treated with Biointo (group A) while another group consisting of 40 IBS patients (15 males, 25 females; mean age 50 +/- 18) did not receive any therapy (group B). RESULTS: Biointol administration improved significantly bloating, flatulence and abdominal pain, with a slight increasing of urgency for bowel movements. On the contrary, Biointol did not show any significant effect on the other IBS symptoms. CONCLUSIONS: Currently, only few agents used in the management of IBS have been proven to be effective. Biointol administration has shown to improve some IBS symptoms, such as bloating, flatulence and abdominal pain, all connected to the presence of gas inside the intestinal lumen.

Long-term antibody persistence and immune memory to hepatitis B virus in adult celiac patients vaccinated as adolescents.

Aim of this study was to investigate the anti-HBs antibody persistence and immune memory to hepatitis B virus in adult celiacs vaccinated as adolescents and the effect of a booster administration in non-protected individuals. Eleven years after primary vaccination, the proportion of vaccinees with titres ≥ 10 mIU/ml and antibody geometric mean concentrations (GMCs) were lower among celiac patients than among controls (68.6% vs 91.7%, p<0.01; GMCs 29.38 mIU/ml vs 250.6 mIU/ml, p<0.001). Participants with anti-HBs below 10 mIU/ml received a booster dose and were retested 2 weeks later to assess the anamnestic response. Post-booster anti-HBs levels were still <10 mIU/ml in 71.4% celiacs and 25% controls (p<0.01). Our findings indicate that the prevalence of seroprotective levels of anti-HBs detected eleven years after primary immunization as well as the frequency of response to a booster dose of vaccine are lower in celiac patients compared to healthy controls.

The quality of sleep in patients with coeliac disease.

BACKGROUND: Coeliac disease is a chronic disease with a various clinical presentation, including anxiety and depression. AIM: To investigate the quality of sleep in coeliac disease. METHODS: The participants were coeliacs at diagnosis; coeliacs on a gluten-free diet at follow-up and healthy volunteers. Participants completed the Pittsburgh Sleep Quality Index (PSQI), SF36, Zung and Fatigue scales and State-Trait Anxiety Inventory (STAI). RESULTS: The PSQI score was higher in coeliacs at diagnosis and in a gluten-free diet than in healthy volunteers (P < 0.001). A gluten-free diet did not improve the PSQI score (P = 0.245) in coeliac disease. The other test scores were similar between coeliacs at diagnosis and those on a gluten-free diet, whereas significant differences were found between coeliacs and volunteers. PSQI score was inversely associated with the quality of the physical (r = -0.327, P = 0.002) and mental (r = -0.455, P < 0.001) component scores. The sleep quality scores were related to depression (r = 0.633, P < 0.001), fatigue (r = 0.377, P < 0.001), state anxiety (r = 0.484, P < 0.001) and trait anxiety (r = 0.467, P < 0.001). CONCLUSIONS: Sleep disorders are common in coeliac disease not only at diagnosis but also during treatment with a gluten-free diet. Sleep disorders are related to depression, anxiety and fatigue, and inversely related to quality of life scale scores.

[Evaluation of occupational exposure to biological agents, endotoxins and PNOC in a sewage treatment plant]. / Valutazione dell'esposizione professionale ad agenti biologici, endotossine e PNOC in un impianto di depurazione.

The aim of this work has been to determine the occupational exposure to the biological agents and airborne dust in a sewage treatment plant in south Italy. The air samplings were performed in a sewage treatment plant in Calabria, in two different seasons (spring and summer) at 5 sites associated with various phases of sewage treatment process. In addition we have estimated the concentration of airborne endotoxins and PNOC (Particles Not Otherwise Classified) by using personal samplers. The results showed a significant variation in exposure to bioaerosols, endotoxins and PNOC depending on the sampling season: the PNOC concentration increase as much as the endotoxins concentration in spring and decrease in summer

[The risk of inhalable wood dust: assessment of workers exposure wood working factories]. / Il rischio da polveri di legno inalabili: valutazione dell'esposizione professionale nelle falegnamerie.

The International Agency for Research on Cancer RC) has classified wood dust as carcinogenic to humans based on demiological and experimental evidence. Exposure to wood dust may use respiratory and dermal symptoms and diseases. The aim of this work was to estimate occupational exposure to inhalable wood dust adopting the formal procedure described by UNI EN 689/97. The exposure of 23 workers in three different working day was measured. In total, 69 personal air samplings were carried out at five wood working factories. Inhalable fraction of airborne dust was collected on 5 microm pore size, 25 mm diameter PVC filters utilizing the IOM samplers. The quantity of the wood dust was determined with gravimetric method. The results show that about 13% of the exposure values exceed the limit of 5 mg/m3 specified by the Italian Law Decree 66/2000 and about 48% of personal exposures are lower then the limit value. Prevention measures, technological solutions and personal protection equipment should be adopted in order to reduce worker's exposure.

[Mount Reventino greenstone: assessment of tremolite fibre dispersion in the workplace]. / Le pietre verdi del Reventino: valutazione della dispersione di fibre di tremolite nelle attività lavorative.

BACKGROUND: Mount Reventino, a massif located in the Calabria Region of Italy, has several ophiolite outcrops of greenstone. These deposits are an important economical resource in the surrounding area. Some rock layers contain tremolite, a type of asbestos fibre. OBJECTIVES: The aim of this paper was to analyze the chemical and physical structure of the outcrops of Mount Reventino, and to assess and reduce the risk to workers associated with exposure to airborne fibres. METHODS: Personal and environmental samples were collected and analysed by Scanning Electron Microscopy equipped with energy-dispersive X-ray analysis. RESULTS: The analysis of samples showed a difference in mineralogical features not only between the quarries under study, but also between the two opposite sides of the mountain. Exploitation of the quarries produces a fibre dispersion that is higher than the natural emission. Occupational exposure to asbestos fibres during greenstone transformation was confirmed by by the results of analysis of the collected samples. CONCLUSIONS: This study made it possible to identify working activities with highest exposure to asbestos and establish the correct procedures to abate fibre dispersion, in order to reduce the correlated risk. Environmental samples collected in the urban area surrounding the quarries showed that the asbestos fibre concentrations were very low, however, further studies are needed in order to confirm these findings.

Atypical pathogens and asthma: can they influence the natural history of the disease?

The association between respiratory infections and asthma exacerbations was first observed in the early '70s. In particular, the role of viral upper respiratory tract infections has been evaluated both in pediatric and adult populations. More recently, evidence of Mycoplasma and Chlamydia pneumoniae involvement in asthma attacks has been reported. These pathogens are also involved in chronic asthma, and both in vitro and animal model studies indicate that atypical agents may play a role in the pathogenesis of the disease. Further research is required to determine whether specific antibiotic treatment may alter the natural history of asthma.

Life supporting first aid (LSFA) teaching to Brazilians by television spots.

Accidents in developing countries are frequent and have high mortality and morbidity rates. In Brazil, in 1995-1996, the year of this study, life supporting first aid (LSFA), which includes cardiopulmonary resuscitation (CPR) basic life support (BLS) was not taught in schools. With the population of 165 million, the only way to teach the adult population on a large scale would be by television (TV), that is widely viewed. This study compares two groups of factory employees - 86 controls without TV exposure to LSFA and 116 exposed to brief LSFA skill demonstrations on TV. Their ability to acquire eight LSFA skills was evaluated: external hemorrhage control; immobilization of a suspected forearm fracture; treatment of a skin burn by cold flush; body alignment after a fall; positioning for shock and coma; airway control by backward tilt of the head; and CPR (steps A-B-C). Simulated skill performance on the evaluating nurse or manikin was tested at 1 week, 1 month, and 13 months. In the control group, 1-31% performed individual skills correctly; as compared to 9-96% of the television group (P<0.001). There was excellent retention over 13 months. Over 50% of the television group performed correctly five of the eight skills, including positioning and hemorrhage control. Television viewing increased correct airway control performance from 5 to 25% of trainees, while it remained at 3% in the control group. CPR-ABC performance, however, was very poor in both groups. We conclude that a significant proportion of factory workers can acquire simple LSFA skills through television viewing alone, except for the skill acquisition of CPR steps B (mouth-to-mouth ventilation) and C (external chest compressions) which need coached manikin practice.

[Cardiac tamponade due to a right atrial myxoma]. / Tamponamento cardiaco da mixoma atriale destro.

A 60-year-old male patient was urgently admitted to the hospital with chest pain, anemia and shock. The echocardiographic examination revealed myocardial tamponade and, unexpectedly, a mobile mass in the right atrium, prolapsing in the right ventricle which was indicative of myxoma. The patient underwent pericardiocentesis which showed the presence of blood. Cardiac surgery was then performed to remove the tumor which was found to originate in the right atrial appendage. There were some adhesions between the atrial appendage and the anterior wall of the right ventricle. The tamponade was due to a trauma of some small pericardial arteries in the adhesion area. The presence of tamponade and right atrial myxoma, is the peculiar finding of the reported case.

[Right atrial thrombosis and pulmonary embolism: role of echocardiography]. / Trombosi atriale destra ed embolia polmonare: ruolo dell'ecocardiografia.

The echocardiographic detection of a right thromboembolus, although rare, should be considered as a cardiological emergency that could lead to death for massive pulmonary embolism. The case of a 70 year-old man admitted to our Institution with the suspicion of pulmonary embolism is described. The echocardiogram performed showed a large mobile thrombus in the right atrium prolapsing through the tricuspid valve during diastole. After thrombolytic therapy with r-TPA, the patient faced a progressive hemodynamic deterioration and died of electromechanical dissociation.

Clinical and hormonal effects of the new angiotensin II receptor antagonist LRB081.

The renin-angiotensin system is a major contributor to the pathophysiology of cardiovascular diseases such as congestive heart failure and hypertension. Antagonizing angiotensin (Ang) II at the receptor site may produce fewer side effects than inhibition of the promiscuous converting enzyme. The present study was designed to assess in healthy human subjects the effect of LRB081, a new orally active AT1-receptor antagonist, on the pressor action of exogenous Ang II. At the same time, plasma hormones and drug levels were monitored. At 1-week intervals and in a double-blind randomized fashion, 8 male volunteers received three doses of LRB081 (10, 40, and 80 mg) and placebo. Blood pressure (BP) was measured at a finger by photoplethysmograph. The peak BP response to intravenous injection of a standard dose of Ang II was determined before and for < or = 24 h after administration of an oral dose of LRB081 or placebo. After drug administration, the blood BP response to Ang II was expressed in percent of the response before drug administration. At the same time, plasma renin activity (PRA), Ang II, aldosterone, catecholamine (radioassays), and drug levels (by high-performance liquid chromatography) were monitored. After LRB081 administration, a dose dependent inhibition of the BP response to Ang II was observed. Maximal inhibition of the systolic BP response was 54 +/- 3 (mean +/- SEM), 63 +/- 2, and 93 +/- 1% with 10, 40, and 80 mg LRB081, respectively. The time to peak was 3 h for 6 subjects and 4 and 6 h for 2 others. Preliminary plasma half-life (t1/2) was calculated at 2 h. With the highest dose, the inhibition remained significant for 24 h (31 +/- 5%, p < 0.05). Maximal BP-blocking effect and maximal plasma drug level coincided, suggesting that the unmetabolized LRB081 is responsible for the antagonistic effect. PRA and Ang II increased dose dependently after LRB081 intake. Aldosterone, epinephrine, and norepinephrine concentrations remained unchanged. No clinically significant adverse reaction was observed during the study. LRB081 is a well-tolerated, orally active, potent, and long-acting Ang II receptor antagonist. Unlike in the case of losartan, no active metabolite of LRB081 has been shown to be responsible for the main effects.

[Arrhythmogenic right ventricular dysplasia. Report of a familial case]. / Displasia aritmogena del ventricolo destro. Descrizione di un caso di familiarità.

Arrhythmogenic right ventricular dysplasia is a pathologic condition of unknown origin that primarily affects the right ventricle free wall characterized by progressive atrophy with fibrous-fatty substitution of the myocardium. The patient affected may present in childhood or as an adult with cardiomegaly or/and ventricular arrhythmias with a left bundle branch block configuration. The reports of familial occurrence suggest the etiologic role of a genetic defect with autosomal dominance and variable expression and penetrance, an alternative, myocarditis (toxic or infectious) is a possible cause. The aim of the present study is an non-invasive instrumental evaluation of the family of a young patient affected by arrhythmogenic right ventricle dysplasia. The authors evaluated 10 patients, 7 women and 3 men, all asymptomatic, with electrocardiography, exercise stress test on a bicycle ergometer, 24-hour Holter monitoring and two-dimensional echocardiography. A patient had certain ARVD diagnosis, while in the other 9 patients all the instrumental investigations were normal. This observation seem to confirm that ARVD may be familial and justify a systematic in-depth familial study in all demonstrated cases of ARVD and the follow-up of all patients identified who had arrhythmias or isolated right ventricular morphologic anomalies.

[Atrial fibrillation induced by massage of the carotid sinus in patients with orthodromic reciprocal supraventricular tachycardia and Wolff-Parkinson-White syndrome]. / Desincronizzazione atriale indotta da massaggio del seno carotideo in paziente con tachicardia sopraventricolare reciprocante ortodromica e sindrome di Wolff-Parkinson-White.

A 46 years old man with WPW syndrome, due to a posteroseptal accessory pathway, was admitted because of orthodromic reciprocating tachycardia, 210/m'in frequency. At the end of the carotid sinus massage, for accomplish the conversion of tachycardia to sinus rhythm, the orthodromic reciprocating supraventricular tachycardia degenerated into atrial fibrillation associated with high ventricular rate and the presence of hemodynamic instability, reverted to sinus rhythm by intravenous propafenone. Vagal stimulation, induced by carotid sinus massage, probably caused dispersion of atrial refractorines and intraatrial reentry, converting the orthodromic tachycardia into atrial fibrillation. The transesophageal electrophysiologic study, executed in treatment with propafenone, not documented the accessory connection and atrial fibrillation or reciprocating tachycardia were not inducible.

Angiotensin-converting enzyme inhibition by hydroxamic zinc-binding idrapril in humans.

The new angiotensin-converting enzyme (ACE) inhibitor idrapril acts by binding the catalytically important zinc ion to a hydroxamic group. We investigated its pharmacodynamic and pharmacokinetic properties in 8 healthy men: Increasing doses of 1, 5, and 25 mg idrapril as well as placebo or 5 mg captopril were administered intravenously (i.v.) at 1-week intervals. Six of the subjects received 100 mg idrapril orally (p.o.) last, and two ingested oral placebo as a double-blind control. Blood pressure (BP) and heart rate (HR) remained unchanged. No serious side effects were observed. ACE inhibition in vivo was evaluated by changes in the ratio of specifically measured plasma angiotensin II (AngII) and AngI concentrations determined by high-performance liquid chromatography/radioimmunoassay (HPLC/RIA) techniques. Plasma ACE activity in vitro was estimated by radioenzymatic assay; it was suppressed by > or = 93% at 15 min after injection of 25 mg idrapril or 5 mg captopril and by 96% 2 h after idrapril intake. Mean AngII levels were decreased dose dependently at 15 min after idrapril injections. At the same time, plasma renin activity (PRA) and AngI increased according to the doses. The AngII/AngI ratio was clearly related to plasma idrapril levels (r = -0.88, n = 60). Oral idrapril inhibited ACE maximally at 1-4 h after dosing, when < 7% of initial ACE activity was observed in vitro and in vivo. Idrapril is a safe and efficient ACE inhibitor in human subjects. It is well absorbed orally. Besides having a slightly slower onset of action, idrapril has pharmacodynamic effects comparable to those of captopril.

[Wolff-Parkinson-White, a study on the prevalence of the site of accessory pathways: relations between stability of pre-excitation, symptoms, cardiac arrhythmias and association of mitral valve prolapse with localization of pre-excitation]. / Wolff-Parkinson-White, studio sulla prevalenza della sede dei fasci anomali: rapporto tra la stabilità della pre-eccitazione, i sintomi, le aritmie cardiache e l'associazione del prolasso valvolare mitralico con la localizzazione della pre-eccitazione.

The aim of this study was to evaluate the prevalence of the anatomic site of accessory pathways using surface electrocardiogram in patients affected by Wolff-Parkinson-White (WPW), and compare it to the stability of preexcitation, symptoms, incidence of arrhythmias, and the possible association of mitral valve prolapse with the localization of preexcitation. From March 1992 to August 1993 at the Cardiology Service of the Civil Hospital "Augusto Murri" in Fermo, USL 21 of the Marche Region, a total of 40 subjects suffering from WPW syndrome were examined prospectively (28 males and 12 females aged between 13 and 75 years). Using surface ECG to evaluate the axis of the delta wave in 12 standard derivations, the authors identified the anatomic site of the accessory pathways. Preexcitation stability was analysed for each patient together with the reported symptoms and the various forms of arrhythmia using dynamic ECG and effort ECG performed using a cycloergometer. Wherever possible an echocardiogram was performed to identify the possible presence of mitral valve prolapse. Out of a total of 40 patients the authors identified 3 cases with an accessory right antero-septal pathway, 13 with an anomalous postero-septal fasciculus, 11 with a right lateral and 13 with a left lateral anomaly. The statistical analysis of data revealed the stability of pre-excitation in 52.5% of cases 55% of patients were found to have a positive record with regard to past symptoms, and supraventricular or ventricular cardiac arrhythmia were diagnosed in 52.5% of the patients examined.(ABSTRACT TRUNCATED AT 250 WORDS)