Complicated systemic lupus erythematosus pancreatitis: pseudocyst, pseudoaneurysm, but real bleeding.

We report the case of a 25-year-old patient with systemic lupus erythematosus (SLE) pancreatitis which was complicated by pseudocyst and pseudoaneurysm formation. The pseudoaneurysm progressed to intra-abdominal bleeding requiring endovascular coil embolization of the gastroduodenal artery. The pseudocyst and hematoma formed two large abdominal fluid collections causing symptoms due to a mass effect. These fluid collections were treated conservatively, while active SLE was treated with steroids, azathioprine, and immunoglobulins. She finally made a full recovery. To the best of our knowledge, this is the first report of a bleeding pseudoaneurysm complicating SLE pancreatitis. Although anecdotal, this case may serve as a useful example of the possible complications of SLE pancreatitis, including considerations on optimal management.

Flares in chronic hepatitis B patients induced by the host or the virus? Relation to treatment response during Peg-interferon {alpha}-2b therapy.

BACKGROUND AND AIMS: Flares are a well known phenomenon during antiviral treatment for chronic hepatitis B. Little is known about the effect of flares on response. We investigated the timing and characteristics of flares, in relation to treatment response (hepatitis B e antigen loss). PATIENTS: A total of 266 patients, participating in a global randomised controlled study, were assigned to 52 weeks of 100 mug pegylated (Peg)-interferon alpha-2b weekly, combined with either daily lamivudine 100 mg or placebo. RESULTS: Sixty seven patients (25%) exhibited 75 flares, with 38 (51%) flares in the combination therapy and 37 (49%) in the monotherapy groups. Overall, 30% of patients with and 38% of patients without a flare responded to therapy (p = 0.25). In 24 patients (36%) the flare was followed by a decrease in hepatitis B virus (HBV) DNA (host induced flare). In 25 (38%) patients the flare was preceded by an increase in HBV DNA (virus induced flare). In 17 (26%) patients the flare did not meet one of these criteria (indeterminate flare). Of patients with host induced flare, 58% responded whereas only 20% of patients with virus induced flares responded (p = 0.008). Hepatitis B surface antigen loss (n = 8) was exclusively seen in patients experiencing a host induced flare. Multivariate logistic analysis showed that host induced flares was an independent predictor of response (p = 0.043). CONCLUSION: Flares are not more common in responders than in non-responders to Peg-interferon alpha-2b therapy. Virus induced flares, which occur after an increase in HBV DNA level, and most probably are indicative for increased expression of viral antigens, did not lead to treatment response. In contrast, host induced flares which were followed by a HBV DNA decrease were highly associated with treatment response.

Influence of the time of measurement of unstimulated human whole saliva on the diagnosis of hyposalivation.

OBJECTIVE: An unstimulated whole saliva flow rate (UWSFR) of less than 0.1 mL/min is often related to symptoms of dry mouth. It is also used as a diagnostic criterion for Sjogren's syndrome, and for assessment of hyposalivation as a caries risk factor. The main hypothesis was that the circadian rhythm of salivary flow affects this diagnosis if saliva is collected at different morning time-points. DESIGN: UWSFR was tested at 7:30 and 11:30 a.m. in 108 individuals, age 15-46 years (mean 33+/-9). The participants were allocated to one of three groups (very low< or =0. 1/min, low 0.1-0.2 mL/min and normal>0.2 mL/min) based on the UWSFR at 7:30 a.m. Different aspects of the perception of oral dryness were rated using Visual Analog Scales. RESULTS: All three groups displayed a statistically significant increase in UWSFR at 11:30 a.m. compared with 7:30 a.m., all of similar magnitude (0.08-0.09 mL/min). In the group with very low UWSFR, 70% at 11:30 a.m. exceeded the 0.1 mL/min limit. There were significant difference in perception of oral dryness between the normal group and both the low and the very low groups. Only the subjects in the groups with a low or very low UWSFR perceived an increase in oral wetness at 11:30 a.m. CONCLUSIONS: It was concluded that the time of measurement strongly influences the diagnosis of hyposalivation. To control the influence of variations in the time of saliva collection, we suggest that unstimulated whole saliva tests are performed at a fixed time-point or in a limited time interval early in the morning.

The safety of pegylated interferon alpha-2b in the treatment of chronic hepatitis B: predictive factors for dose reduction and treatment discontinuation.

BACKGROUND: Treatment with interferon-alpha has been shown to be effective in one-third of hepatitis B e antigen-positive chronic hepatitis B patients, but is clinically associated with relevant adverse events. AIM: To investigate the safety of pegylated interferon alpha-2b in 300 hepatitis B e antigen-positive patients with compensated liver disease. METHODS: Patients were treated with pegylated interferon alpha-2b for 52 weeks combined with either lamivudine 100 mg/day or placebo. Pegylated interferon alpha-2b was administered for 100 microg once a week for 32 weeks; thereafter, the dose was reduced to 50 microg once a week. Adverse events and their effect on study medication were reported at monthly visits in a standardized way. RESULTS: The most frequently reported side-effects were flu-like syndrome (68%), headache (40%), fatigue (39%), myalgia (29%) and local reaction at the injection site (29%). These symptoms typically occurred within the first month of therapy and subsided during the course of therapy. Neutropenia and thrombocytopenia induced by pegylated interferon alpha-2b increased the risk of infections and bleeding complications, but these complications were rare and mild. The frequency of all side-effects was not different between patients treated with pegylated interferon alpha-2b combined with lamivudine or placebo. In 69 (22%) patients the dose of pegylated interferon alpha-2b was reduced prematurely. Of these dose reductions, 36 (52%) were because of neutropenia. Therapy was discontinued in 28 (8%) patients. The most frequent reasons for early discontinuation were psychiatric side-effects (depression, psychosis) and flu-like symptoms. Multivariate Cox regression analysis showed that low neutrophil count at baseline and cirrhosis were independent predictors of dose reduction or therapy discontinuation. CONCLUSION: We conclude that in patients with chronic hepatitis B and compensated liver disease prolonged pegylated interferon alpha-2b therapy is safe, and that pre-existent cirrhosis and neutropenia are the most important predictors of dose reduction or early treatment discontinuation.

Early and late mortality after surgery for unstable angina in relation to Braunwald class.

BACKGROUND: The prognostic value of the preoperative Braunwald class of unstable angina to predict early and long-term outcome after urgent coronary artery bypass grafting (CABG) has not been studied previously. METHODS: Deaths were recorded after all primary isolated CABG performed for unstable (n = 992) and stable (n = 5376) angina pectoris during 1980-1995. Severity of symptoms in the unstable patients was classified according to Braunwald. RESULTS: Death within 30 days of surgery occurred in 4.6% of the patients having unstable angina and in 1.6% of those with stable angina. Early mortality was 2.5% in Braunwald class II, 4.9% in class IIIB, and 6. 2% in class IIIC unstable patients. The risk of early death, after adjustment for risk factors, was about four times higher in Braunwald class IIIB (odds ratio [OR] 4.3, 95% confidence interval [CI] 2.4-7.7) and IIIC (OR 4.7, 95% CI 2.2-10.3) patients than in stable patients. The risk of death during postoperative months 1 to 6 tended to be higher (relative risk 2.4, 95% CI 0.8-7.1) in Braunwald class IIIC patients than in stable patients. After the first 6 months up to 5 years, survival rates in all Braunwald classes were similar to those in patients operated on for stable angina. CONCLUSIONS: There was a higher risk of early death after urgent bypass surgery in patients with Braunwald class III unstable angina than after elective CABG. The long-term survival rates after the first 6 postoperative months was similar in stable and unstable patients, regardless of preoperative Braunwald class.

Hyposalivation and iron stores among individuals with and without active dental caries.

The aims of the study were to investigate frequencies of low unstimulated whole saliva (UWS) levels and low serum ferritin (S-f) levels among individuals with active dental caries (ADC) and dental caries inactive (DCI) individuals and to compare the relationship between UWS and S-f levels. In this descriptive study, 48 ADC patients and 48 DCI individuals were compared. The two groups were matched regarding age and sex (30 females and 18 males in each group, age range 15-40 years). In the ADC group, 32 individuals (67%) had low (< or = 0.20 ml/min) UWS levels compared with 13 individuals (27%) in the DCI group. This difference was statistically significant (P < 0.001). The mean values of UWS were significantly lower in the ADC group compared to the DCI group (mean ml/min +/- SD) 0.20 +/- 0.13 and 0.33 +/- 0.24, respectively (P = 0.002). There were significant differences for females but not for males when comparing frequencies of low UWS levels (P < 0.001) and mean UWS levels (P = 0.002). There was no difference in S-f levels between the two groups. Neither was any correlation between UWS and S-f found. In conclusion, the significant negative relationship found between UWS and ADC indicates that a suppressed defense for dental caries activity could play a more important role in ADC than previously presumed, especially among females. The absence of a correlation between UWS and S-f might indicate that saliva secretion will not be stimulated by iron supplementation.