Acrylate glue injection for acutely bleeding oesophageal varices: A prospective cohort study.

BACKGROUND: Acrylate glue injection is seldom performed in patients with bleeding oesophageal varices. AIM: To assess efficacy and safety of acrylate glue injection in patients with bleeding oesophageal varices, as well as the impact of this technique on subsequent variceal ligation. METHODS: Prospective study on 133 consecutive cirrhotic patients treated by intravariceal injection of undiluted N-butyl-2-cyanoacrylate into the bleeding varix. Outcome measures were initial haemostasis, recurrent bleeding, complications and mortality at 6 weeks. RESULTS: 52 patients were actively bleeding at endoscopy and 81 showed stigmata of recent haemorrhage. Initial haemostasis was achieved in 49/52 active bleeders (94.2% [95% CI 85.1-98.5]). Overall, early recurrent bleeding occurred in 7 patients (5.2% [95% CI 2.3-10.1]). No major procedure-related complication was recorded. At 6 weeks, death occurred in 11 patients, with an overall bleeding-related mortality of 8.2% [95% CI 5.8-15.3]. Mortality was higher in active (15.4% [95% CI 6.9-28.1]) than non-active bleeders (3.7% [95% CI 0.8-10.4], OR 4.7 [95% CI 1.05-28.7], p=0.02). Of those surviving the first bleeding episode, 112 patients subsequently underwent ligation. No technical difficulties were encountered in performing the banding procedure which was successfully completed in all cases. CONCLUSIONS: Emergency injection of acrylate glue is safe and effective for the treatment of acute bleeding oesophageal varices and does not hamper subsequent variceal ligation.

Confocal laser endomicroscopy in celiac disease: description of findings in two cases.

Duodenal confocal laser endomicroscopy (CLE) was carried out in six patients to compare the findings with histology. The visibility and quality of the endomicroscopy images were quantified using the following score: 0 = none; 1 = poor; 2 = fair; 3 = good. Four patients had a normal duodenal mucosa, whereas two patients in whom CLE indicated villous atrophy showed histologic features typical of celiac disease. Histology and CLE images were similar in both normal and celiac disease patients; patients with celiac disease had an average score of 3 for epithelial architecture, 3 for goblet cells, 3 for vessels, 1 for inflammatory infiltrate, and 2 for crypt visibility.

Doppler ultrasonographic grading of hepatic vascular malformations in hereditary hemorrhagic telangiectasia -- results of extensive screening.

AIMS: In previous studies, the prevalence of hepatic vascular malformations (VMs) in a large Italian family with hereditary hemorrhagic telangiectasia (HHT) was examined by Doppler ultrasonography (US) as screening technique, and the relevant Doppler US findings were described and classified. Thereafter, Doppler US has been routinely used to screen HHT families for liver involvement. Hepatic VMs were evaluated and classified on the basis of Doppler US findings. METHODS: Three hundred and forty-six subjects belonging to 64 pedigrees were checked for the presence of signs of HHT. All of them underwent abdominal Doppler US screening for hepatic VMs. Vascular abnormalities were classified as minimal if the hepatic artery was dilated in extrahepatic tract only and measured > 6 mm; as moderate if the hepatic artery was dilated in both intra and extrahepatic tract; and as severe if complex changes of the arterial hepatic branches were associated with hepatic and/or portal vein dilatation. Furthermore, Doppler parameters, both qualitative (flow direction, turbulence) and quantitative (peak flow velocity and resistivity index in hepatic artery, mean velocity in portal vein, diastolic peak flow velocity in hepatic veins), were entered into our VM classification. RESULTS: HHT was found in 222 subjects, with hepatic VMs detected by Doppler US in 92 (41.4 %) (24 males, 68 females, mean age 52.2). Hepatic VMs were minimal in 11 subjects, moderate in 70, and severe in 11. CONCLUSIONS: On the basis of our proposed grading, hepatic VMs can be easily classified in subjects with HHT by Doppler US. Depending on the degree of hepatic vascular derangement, appropriate programs for follow up and/or therapy can be designed.

Prospective randomized trial comparing Tannenbaum Teflon and standard polyethylene stents in distal malignant biliary stenosis.

BACKGROUND: Our aim was to compare the clinical efficacy of the Tannenbaum (TB) biliary prostheses, a recently designed Teflon stent without side holes, with the Cotton-Huibregtse (CH) polyethylene stent. METHODS: Fifty-seven patients (26 men, mean age 75.5 years) with unresectable malignant tumors and distal biliary stenosis were included (38 pancreatic head cancer, 17 cholangiocarcinoma, 2 ampullary cancer). Patients were prospectively randomized to have a 10F, 7 cm long TB (29 patients) or CH (28 patients) stent inserted endoscopically. Four patients (2 TB and 2 CH) were excluded: 3 because of the failure of stent insertion and 1 because of a protocol violation. The patients were evaluated clinically and, if necessary, with biochemical tests every month until death or until they needed surgery for symptoms of gastric outlet obstruction. When occlusion or dislocation occurred, the stent was replaced with one of the same type. Cumulative stent patency and patient survival were estimated with the Kaplan-Meier life-table analysis and compared by log-rank chi-square test. RESULTS: The two groups were comparable in mean age, gender, and diagnosis. The patients were followed for a mean of 145.5 days (range 24 to 613); by the end of the study 47 patients (81%) had died or developed symptoms of gastric outlet obstruction. Median survival was 88 days (range 24 to 613) in the TB group and 75.6 days (23 to 486) in the CH group. Stent exchange (occlusion 16, dislocation 3) was necessary for 5 patients in the TB group and 7 in the CH group. No statistical difference was found on comparing the mean duration of function of the first, second, and third stents (analysis of variance, p = 0.80). The median duration of stent function was 96 days (range 11 to 613) in the TB group and 75.5 days (range 23 to 323) in the CH group. No significant difference was found in either survival time (p = 0.48) or stent patency (p = 0.12). CONCLUSION: This study found no significant advantage of the Tannenbaum prostheses over the standard polyethylene stent in the palliation for patients with distal malignant biliary stenosis with regard to survival or length of stent patency.

[Surgical treatment of varicocele. Our experience in the last 10 years]. / Trattamento chirurgico del varicocele. Nostra esperienza negli ultimi 10 anni.

UNLABELLED: Varicocele means a varicose dilatation with stretching of the veins in the pampiniform plexus. In the last years the problem of varicocele has emerged again in all its importance for the increasing of couple sterility which, in Italy, is certified to 13%. It is known that this problem is connected to anomalies of the spermiogram, even in the subclinical forms located with the ultrasound method, and that the surgical operation allows to correct in a high percentage of cases. MATERIALS AND METHODS: For treatment of varicocele we use a technique with inguinal approach of 5-6 cm and isolation of all the dilated veins intra- and extrafunicular. After their ligation and section we transpose the funiculus proximally with a little traction on the testicle and we fix it to the great oblique muscle fascia, using margin of cremasteric muscle prepared in advance and distal stumps of resected veins. This manoeuvre forms a short ansa of the funiculus that, in the orthostatic position, helgs to stop the hematic column which weighs on the testicle. This operation has been performed in 54 patients. In 18 (60%), oligoastenospermia was present and 10 (33%) had consulted their physician for sterility problems (4 of them with a sub-clinical varicocele). The patients have been recalled for clinical and echo-doppler control as well qualitative evaluation of the sperm. The follow-up goes from 8 months to 7 years. RESULTS: We have noticed the presence of six relapses (13.3%) so divided: 4 relapses with a first grade reflux; 1 relapse with a second grade reflux and 1 relapse with a third grade reflux. Only in two patients with first grade reflux was the spermiogram normal, while in all the others oligoastenospermia persisted. Seric evaluation of testosterone and androstenedione have excluded hormonal causes of sterility. Among the 10 sterile patients 6 (60%), had a normalization of the spermiogram and 4 of them (2 of which with preceding subclinical varicocele), had a partner pregnancy in periods within 7 and 18 months after the operation. CONCLUSION: On the basis their experience, the authors confirm the validity of the selective varicocelectomy by inguinal approach, with probable further advantage using funicular transposition. To agree with other authors there isn't any very important advantage, in the cost/benefit ratio, between microsurgical diversion and laparoscopic surgery, and traditional varicocelectomy in local anesthesia. The incidence of relapses noticed (13.3%), lower than that rated at the high ligature (29%), is the expression of the anatomic complexity of the spermatic venous drainage, in such a way to think right a phlebographic anterograde intraoperative evaluation. We also confirm the importance of ultrasonographic and ecographic methods in the pre and postoperative evaluation, we underline that, in the subclinical cases, it is possible to verify spermiogram alteration corrected, in a high percentage, by varicocelectomy.

Pharmacokinetics of rimantadine hydrochloride in patients with chronic liver disease.

Six patients with chronic liver disease and six sex-, age (+/- 5 years)-, and weight (+/- 5 kg)-matched healthy control subjects received a single dose of two 100 mg tablets rimantadine HCl. Eight additional patients with chronic liver disease who were not matched to healthy subjects received a single dose of two 100 mg tablets of rimantadine HCl. Blood and urine samples were collected and rimantadine concentrations were determined by a GCMS method. The values for maximum plasma concentration, AUC, elimination half-life, and renal clearance were not significantly different between patients and control subjects, independent of the statistical analyses (parametric and nonparametric) used. The mean apparent elimination half-life, volume of distribution, and total clearance in the matched patients with liver disease were 32 hours, 24 L/kg, and 676 ml/min, respectively. Renal clearance and the amount excreted in the urine unchanged were 63 ml/min and 10%, respectively. In conclusion, rimantadine pharmacokinetics were not appreciably altered in patients with less severe chronic liver disease.

Determination of 6-(2'-chlorophenyl)-4-hydroxy-4H-imidazo[1,5-a] [1,4]benzodiazepine-3-carboxamide, a mixed agonist-antagonist anxiolytic agent, in human plasma and urine by gas chromatography-negative-ion chemical-ionization mass spectrometry.

A simple, sensitive and specific assay was developed for the determination in plasma and urine of 6-(2'-chlorophenyl)-4-hydroxy-4H-imidazo[1,5-alpha] [1,4]benzodiazepine- 3-carboxamide, compound I, a mixed agonist-antagonist anxiolytic agent. A hexadeuterated analogue of the compound was added to plasma or urine as the reference standard. The titled compound was extracted with benzene at pH 11. Following evaporation of the solvent, the residue was reacted with pentafluoropropionic anhydride in the presence of triethylamine. The derivatizing reagents were evaporated, and the carbonitrile derivative of the analyte was extracted into ethyl acetate at pH 11. The residue remaining after removal of the ethyl acetate was silylated with bis(trimethylsilyl)trifluoroacetamide, and a portion of this solution was analyzed by gas chromatography-negative-ion chemical-ionization mass spectrometry. The mass spectrometer was set to monitor, in the gas chromatographic effluent, the M-. ion of the titled compound and its hexadeuterated reference standard. The ratio of these two ions was calculated and converted to a concentration of analyte using a calibration curve that was generated from the analyses of control plasma fortified with various amounts of analyte and a fixed amount of the hexadeuterated reference standard. The limit of quantitation of the assay was 1 ng/ml for plasma and urine.

Quantitative determination of rimantadine in human plasma and urine by GC-MS.

A GC-MS procedure has been developed for the quantitation in plasma and urine of rimantadine, an antiviral drug effective against type A influenza. The assay utilizes selective ion monitoring, methane negative ion chemical ionization (NCI) and stable isotope dilution. Sensitivity to NCI is effected by derivation of rimantadine with pentafluorobenzoyl chloride. The method has been used to quantitate plasma concentrations of rimantadine over a range from 4.2 ng/ml to 416 ng/ml, and urinary concentrations of rimantadine over a range of 21 ng/ml to 2077 ng/ml.

Determination of (-)-threo-chlorocitric acid in human plasma by gas chromatography-positive chemical-ionization mass spectrometry.

A method is described for measuring (-)-threo-chlorocitric acid in human plasma. Plasma is acidified to pH 1 to minimize lactonization and a 13C analogue of (-)-threo-chlorocitric acid is added as internal standard. The acidified plasma is then extracted with ethyl acetate containing 10% methanol. The ethyl acetate-methanol extract is back-extracted with acetate buffer (pH 5). This extract, following adjustment to pH 1, is reextracted with ethyl acetate. The residue after removal of the ethyl acetate is treated with ethereal diazomethane. The wet residue is reconstituted in ethyl acetate and a portion of this solution is analyzed by gas chromatography-chemical ionization mass spectrometry. The mass spectrometer is set to monitor m/z 269 [MH+ of trimethylated (-)-threo-chlorocitric acid] and m/z 270 [MH+ of trimethylated (-)-threo-[13C]chlorocitric acid] in the gas chromatographic effluent. The m/z 269 to m/z 270 ion ratio in a sample containing an unknown amount of (-)-threo-chlorocitric acid is converted to an amount of compound using a calibration curve. The calibration curve is generated by analyzing control plasma spiked with various known amounts of (-)-threo-chlorocitric acid and a fixed amount of (-)-threo-[13C]chlorocitric acid. The limit of quantitation is 0.1-0.6 micrograms ml-1, depending on the characteristics of the calibration curve generated with each set of samples. The precision (relative standard deviation) at a concentration of 2 micrograms ml-1 is 3.3%.

[A technic of analgesic anesthesia as brief anesthesia]. / Una tecnica di anestesia analgesica come anestesia breve.

An original technique of analgesic anaesthesia, with the characteristics of brief and out-clinic anaesthesia, has been experimented in a group of patients undergoing light surgery (eye surgery). The technique employs an association of an analgesic--Fentanil--a low dose hypnotic and marked hyperventilation. Recovery characteristics have been assessed by studying neuromuscular and psychoaptitudinal recovery times (Romberg negativisation). The results show that this technique may be worthily included among the best techniques of brief anaesthesia.

[Study of recovery from anesthesia by means of graphic tests of writing and drawing]. / Studio del recupero dalla narcosi mediante prove grafiche di scrittura e disegno.

As part of an investigation of the quality of the return to consciousness after anaesthesia, a comparison was made between recovery times in 60 patients divided into three groups, subjected to general anaesthesia and shallow maintenance with halothane, mixed short shallow neuro-analgesia, and short analgesia anaesthesia. Psycho-aptitudinal recovery was evaluated with three graphic tests. The results indicate that recovery times are much shorter for shallow neuro-analgesia, and particularly for analgesic anaesthesia by comparison with ordinary shallow techniques coupled with maintenance in O2 + N2O + Halothane.