Personnel real time dosimetry in interventional radiology.

Interventional radiology and hemodynamic procedures have rapidly grown in number in the past decade, increasing the importance of personnel dosimetry not only for patients but also for medical staff. The optimization of the absorbed dose during operations is one of the goals that fostered the development of real-time dosimetric systems. Indeed, introducing proper procedure optimization, like correlating dose rate measurements with medical staff position inside the operating room, the absorbed dose could be reduced. Real-time dose measurements would greatly facilitate this task through real-time monitoring and automatic data recording. Besides real-time dose monitoring could allow automatic data recording. In this work, we will describe the calibration and validation of a wireless real-time prototype dosimeter based on a new sensor device (CMOS imager). The validation measurement campaign in clinical conditions has demonstrated the prototype capability of measuring dose-rates with a frequency in the range of few Hz, and an uncertainty smaller than 10%.

A comparison of risk factors as predictors of cardiovascular and non-cardiovascular mortality in the elderly people--relevance of N-terminal pro-B-type natriuretic peptide and low systolic blood pressure.

BACKGROUND: Many risk factors are known to predict ischaemic events and mortality in the elderly people, but their ranking of importance remains uncertain. This study was designed to identify and compare the main predictors of total mortality (TM), cardiovascular mortality (CVM) and non-cardiovascular mortality (NCVM) in older adults. METHODS: Nine hundred and seventy-nine community resident adults aged ≥ 65 years, free of previous heart failure and cardiovascular events, participated in the study. The univariate and multivariate (Cox regression) relationships of baseline cardiovascular risk factors, treatments and laboratory data with TM, CVM and NCVM were assessed after a median follow up of 6.7 years. RESULTS: Overall, there were 104 deaths (30 because of CVM and 74 to NCVM). In multivariate analysis, the following factors remained independently associated with mortality: NT pro-B-type natriuretic peptide (NT-proBNP) upper quintile (≥ 237 pg/ml for men, ≥ 280 pg/ml for women): hazard ratio (HR) vs. the rest of the population (95% confidence interval) 2.34 (1.52-3.60), p < 0.001 for TM; HR 5.41 (2.32-12.65), p < 0.001 for CVM; systolic blood pressure lower quintile (≤ 130 mmHg): HR 3.06 (1.80-5.21), p < 0.001 for NCVM; diabetes: HR 2.46 (1.29-4.72), p = 0.007 for NCVM; erythrocyte sedimentation rate (ESR) upper decile (≥ 41 mm/h): HR 2.33 (1.16-4.69), p = 0.02 for NCVM; platelet count lower quintile (≤ 177 × 10(9) /l): HR 2.09 (1.20-3.64), p = 0.009 for NCVM; ever-smoker status: HR 2.08 (1.23-3.52), p = 0.007 for NCVM. CONCLUSIONS: In elderly community dwellers, NT-proBNP was the strongest predictor of TM and CVM, while especially low systolic blood pressure, together with diabetes, ESR, reduced platelet count and ever-smoker status, were the main predictors of NCVM.

Age dependency of regional impedance indices regardless of clinical stage in patients with cirrhosis of the liver.

PURPOSE: To prospectively assess if ageing itself induces modifications of the impedance indices (resistance and pulsatility indexes) of hepatic, splenic, superior mesenteric and renal arteries in patients with liver cirrhosis. MATERIALS AND METHODS: 78 consecutive patients with cirrhosis (41 males, 37 females, Child-Pugh score 7 [range 5 - 12]) were studied by colour-Doppler ultrasound. The resistance index (RI) and pulsatility index (PI) were determined in the main hepatic artery, intraparenchymal branches of hepatic, splenic, and renal arteries, and superior mesenteric artery; clinical data were simultaneously collected. Logistic regression analysis was performed to assess the relative impact of age, severity of liver disease and other relevant variables on the increase of impedance indices. Linear regression analysis was used to identify a coefficient to adjust RIs and PIs to age. RESULTS: Resistance and pulsatility indices of all the vessels studied except of the superior mesenteric artery showed a direct correlation with age (e. g. splenic artery RI: R = 0.520, p < 0.0001), and correlated most strongly with Child-Pugh score (e. g. right renal artery PI: R = 0.462, p < 0.0001). Age was associated independently with increased PI and RI in hepatic, splenic and renal arterial districts. In these vessels, the RI threshold of normality can be adjusted to the decade of age adding a correction of 0.03. CONCLUSION: Ageing itself induces an increase of hepatic, splenic and renal impedance indices in cirrhotic patients. The threshold of normality for these indices in cirrhosis should be adjusted according to the patients' age.

Physical activity is negatively associated with the metabolic syndrome in the elderly.

BACKGROUND: An inverse association between physical activity and metabolic syndrome has been reported in several cohorts, but very few specific studies are available in the elderly, in whom neurological and musculo-skeletal diseases are expected to lead to a remarkable age-related decline of physical activity. AIM AND DESIGN: The relationships among physical activity, insulin resistance and metabolic syndrome were assessed in a cross-sectional study concerning 1144 subjects aged 65-91 years resident in Pianoro (northern Italy). Household and leisure-time activities were assessed by a self-administered questionnaire (Physical Activity Scale for Elderly--PASE). Routine clinical and biochemical data (including fasting insulin) were used to assess insulin resistance [Homeostasis Model Assessment (HOMA) method] and the prevalence of metabolic syndrome. RESULTS: All PASE scores were inversely correlated with waist circumference, triglycerides and HOMA index, with highest significance for leisure-time activities (P < or = 0.005). The PASE score for household activities was also correlated inversely with blood glucose (P < 0.05), and directly with HDL cholesterol (P < 0.001). In logistic regression analysis, the metabolic syndrome was more prevalent among sedentary subjects (corresponding to the low tertile of leisure-time activities) than in the remaining more active population (odds ratio 1.51, 95% confidence interval 1.12-2.03, P = 0.007), independently of possible confounders. CONCLUSION: Physical activity is inversely associated with insulin resistance and the metabolic syndrome even in the elderly. Community programs favoring physical activity are expected to significantly improve the health status in these subjects.

New abdominal collaterals at ultrasound: a clue of progression of portal hypertension.

BACKGROUND: Abdominal ultrasound can detect non-invasively the presence of abdominal portal-systemic collaterals in patients with liver cirrhosis. Abdominal portal-systemic collaterals may be protective from the formation and growth of oesophageal varices, but available data are inconclusive. AIM: We aimed at investigating the relationship between abdominal portal-systemic collaterals and variceal formation and growth. METHODS: We studied 126 cirrhotic patients without (n=43) or with small (n=83) oesophageal varices who entered a protocol of serial ultrasonographic and endoscopic examinations for a median of 55 months. Presence and kind of abdominal portal-systemic collaterals was recorded on first ultrasonography and on each control thereafter. RESULTS: At inclusion, abdominal portal-systemic collaterals were found in 19/43 patients without varices and in 23/83 patients with small varices (NS). There was no difference in variceal formation and growth between patients with and without abdominal portal-systemic collaterals at inclusion. However, patients developing new abdominal portal-systemic collaterals during follow-up had a significantly higher rate of variceal formation (56.2% vs. 22.2%; p=0.024) and growth (52.9% vs. 30.6%; p=0.041) compared with patients with unchanged ultrasonography. CONCLUSIONS: Abdominal collaterals are not protective from the formation or growth of oesophageal varices. Conversely, new abdominal portal-systemic collaterals emergence is a non-invasive clue of formation and progression of varices. Therefore, endoscopy is probably indicated whenever new abdominal portal-systemic collaterals are detected in cirrhotic patients.

Octreotide in the outpatient therapy of cirrhotic chylous ascites: a case report.

Chylous ascites is a rare complication of liver cirrhosis associated with a poor short-term prognosis. We report the case of an 80-year-old male cirrhotic patient with refractory chylous ascites associated with portal hypertension. He was treated with total parenteral nutrition but chylous ascites relapsed at suspension. Patient was put on long-term subcutaneous octreotide (100 microg t.i.d.) as an outpatient. The treatment was well tolerated and led to clinical improvement, markedly reducing the need of total paracentesis and the amount of ascites. Octreotide was stopped after 6 months, and massive ascites did not relapse. After 1 year the patient was alive, with no need of paracentesis. Octreotide therapy should be considered in patients with cirrhosis and chylous ascites to simplify the outpatient management of the disease.

Splanchnic haemodynamics in non-alcoholic fatty liver disease: effect of a dietary/pharmacological treatment. A pilot study.

BACKGROUND: Previous studies demonstrated that in experimental animals fatty liver is associated with reduced hepatic blood flow and that metformin reverses steatosis, while no data were reported in humans. AIMS: To evaluate the clinical relevance of echo-Doppler measurements and the effects of therapy in non-alcoholic fatty liver disease. PATIENTS: Twenty patients with biopsy proven non-alcoholic fatty liver disease. METHODS: Abdominal echo-Doppler examination was performed at enrolment and, in 11 patients, after 6 months of dietary/pharmacological therapy (metformin 500 mg three times a day). RESULTS: Non-alcoholic fatty liver disease was characterised by hepatomegaly, bright echotexture and posterior attenuation. Mean portal blood velocity and flow were low-normal. Brightness and posterior attenuation significantly correlated with fat score in liver biopsies as well as with the hepatic veins spectrum. After therapy, echotexture improved and liver volume significantly decreased. Portal blood velocity and flow significantly increased, intrahepatic arterial indexes decreased and the spectrum of hepatic veins improved. CONCLUSIONS: Fatty liver is associated with an impaired hepatic blood flow characterised by increased intrahepatic resistances. Vascular changes are reversed by treatment and can be measured by echo-Doppler which may be useful to evaluate the natural course of non-alcoholic fatty liver disease, and to monitor the putative beneficial effects of therapy.

Perception of health-related quality of life and psychological status in oldest hospitalized patients without cognitive impairment.

The most diffuse questionnaires on health-related quality of life (HRQL) and/or psychological status (PS) consider all subjects older than 74 years, for normative reference values, in a single group without any further separation for age decades. Their authors assume that there are no further age-related differences, since older patients had a severely limited autonomy and lose the capacity of grading the severity of the diseases they are affected. Healthy subjects older than 80, without mental impairment (WMI) present an acceptable HRQL, PS and a perception of health status. No data are available on the oldest patients, carrying chronic diseases, admitted to hospital departments for acute health problems.We collected 46 WMI oldest patients (>/= 80 years), admitted for such troubles. They were investigated by the mini mental state examination (MMSE) and, in random order, the Nottingham health profile (NHP) and the psychological general well-being instrument(PGWBI). Clinical data recordings were carried out by the medical personnel, using standardized forms. The value of any individual domain of each patient was compared to the age - (>/=75-year) and sex-matched control group derived from two large Italian population studies, using the Z-score. Charlson's comorbidity index, the index of coexistent disease (ICED), and the cumulative illness rating scale (CIRS) were also calculated. Patients older than 80 did show difference in NHP domains in comparison with normative values only for social isolation, but presented significantly worse Z-scores in all domains ofPGWBI. A relationship was observed between number of daily medications and Z-scores of physical mobility and energy (NHP). Similarly, vitality (PGWBI) correlated with all comorbidity indices, ICED with positive well-being (PGWBI), pain (NHP) with CIRS subscales. Hospitalized WMI oldest subjects maintain a HRQL quite comparable to normative group of subjects older than 74 years. Furthermore, they showed a preserved correct perception of factors/diseases that possibly affect their psychological status and autonomy.

Splanchnic haemodynamics in patients with coeliac disease: effects of a gluten-free diet.

BACKGROUND: Coeliac disease is characterized by structural and functional changes in the small bowel which may also result in haemodynamic changes. AIMS: To establish whether splanchnic haemodynamics can be modified by a gluten-free diet. PATIENTS: Ten coeliac patients and 10 paired healthy subjects. METHODS: Echo-Doppler measurements were made of splanchnic vessels both fasting and after a standard meal before and after 9 months of a gluten-free diet. RESULTS: In comparison to controls, coeliac patients had higher superior mesenteric artery blood velocity and flow, with lower resistance indexes and higher portal vein velocity and flow, particularly 3 h after a meal. Postprandial hyperaemia was reduced and delayed in time. Intrasplenic resistance indexes were also significantly lower both fasting and after a meal. After 9 months of a gluten-free diet, no significant differences were observed between coeliac patients and controls, both fasting and after a meal. CONCLUSIONS: Splanchnic haemodynamics is significantly changed in coeliac patients, mainly after a meal. On treatment with a gluten-free diet, both fasting and postprandial haemodynamics became normal.

Impact of interferon therapy on the natural history of hepatitis C virus related cirrhosis.

BACKGROUND: The role of interferon treatment on the natural history of hepatitis C virus related cirrhosis is under debate. AIM: To evaluate the effect of interferon on the clinical course of compensated hepatitis C virus related cirrhosis. PATIENTS AND METHODS: Seventy two cirrhotic patients treated with interferon and 72 untreated controls matched treated patients with for quinquennia of age, sex, and Child-Pugh's score were enrolled in a prospective non-randomised controlled trial. Treated patients received leucocytic interferon alfa, with an escalating schedule for 12 months. The incidence and risk (Cox regression analysis) of clinical complications (hepatocellular carcinoma, ascites, jaundice, variceal bleeding, and encephalopathy) and death were calculated. RESULTS: Over median follow up periods of 55 months for treated and 58 for untreated subjects, seven and nine patients, respectively, died, and 20 and 32, respectively, developed at least one clinical complication (ns). Hepatocellular carcinoma developed in six treated and 19 untreated patients (p=0.018). Seven treated patients showed sustained aminotranferase normalisation and none died or developed complications. Clinical complications were significantly associated with low albumin, bilirubin, and prothrombin activity while hepatocellular carcinoma was significantly related to no treatment with interferon, oesophageal varices, and high alpha fetoprotein levels. By stratified analysis, the beneficial effect of interferon was statistically evident only in patients with baseline alpha fetoprotein levels > or =20 ng/ml. CONCLUSIONS: Interferon does not seem to affect overall or event free survival of patients with hepatitis C virus related cirrhosis while it seems to prevent the development of hepatocellular carcinoma. Patients who achieved sustained aminotransferase normalisation survived and did not develop any complications during follow up.

Prognostic indicators of risk for first variceal bleeding in cirrhosis: a multicenter study in 711 patients to validate and improve the North Italian Endoscopic Club (NIEC) index.

OBJECTIVE: The best known indicator of risk for first bleeding in patients with cirrhosis without previous bleeding is the index devised by the North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices (NIEC index), which results from the combination of size of esophageal varices, severity of red wale marks, and Child-Pugh class. Its efficiency is far from optimal, and validation studies have reported sensitivities and specificities markedly lower than those reported in the original study. In the present study we analyzed the efficiency of NIEC index in a large series of cirrhotic patients with varices without previous bleeding. In addition, we tried to improve the effectiveness of the index by modifying it, and to validate the modifications in an independent group of patients. METHODS: A total of 627 patients were enrolled and followed until either a variceal bleeding or for a maximum of 2 yr. During this time, 117 experienced a first variceal RESULTS: Using Cox's regression analysis, size of varices, severity of red wale marks, and Child-Pugh score were significant and independent predictors of first bleeding, as already noted in the original report of the NIEC group. However, coefficients and standard errors were markedly different, and the importance of size of esophageal varices in the regression was much larger, whereas that of Child-Pugh score was much lower. According to these data, a revised index was developed (Rev-NIEC). Using receiver operating characteristic (ROC) curve analysis, the revised index showed a larger efficiency, and the area under the curve was significantly larger (0.80 +/- 0.02 vs 0.74 +/- 0.02; p < 0.01). In particular, the curve showed that for a specificity of 75%, the new index had a sensitivity of 72% compared to that of 55% of the NIEC index. Validation in an independent sample of 84 patients showed good agreement between predicted and observed risk for bleeding. Validation with the bootstrap technique also showed adequate stability of the results. CONCLUSIONS: The revised index seems to be superior to the traditional index, and may turn out to be more useful in the selection of patients for different therapeutic procedures and in the stratification of patients in clinical trials.

Natural history of cirrhotic patients with small esophageal varices: a prospective study.

OBJECTIVE: Contrasting data are available on the natural history and bleeding risk of small esophageal varices. The aim of this prospective study was to evaluate a large series of consecutive cirrhotics with a first endoscopic diagnosis of small varices. METHODS: Between 1987 and 1992, 258 patients with small varices and no previous bleeding were enrolled. Patients were clinically examined every 6 months and were followed until a first episode of bleeding and/or death, or until June 1998. None received any treatment to prevent bleeding. Endoscopies were planned at 18-month intervals. RESULTS: The cumulative risk of bleeding was low (3% at 2 yr and 8% at 4 yr) and remained low in patients in whom varices remained small at 2nd endoscopy, whereas it increased significantly when varices enlarged. The increase of varices appeared to be rather linear in time: at the 2nd endoscopy varices remained small in 79% of patients and increased in 21%; at the 3rd endoscopy varices remained small in 55%, whereas at the 4th 33% of patients still had small varices. Clinical and biochemical data at the 1st and 2nd endoscopy were included in a multiple logistic regression analysis. Only the increase in Child-Pugh score appeared to be a significant predictor of enlarged varices; the risk of aggravation increased by 37.5% for every unit of impairment of the score. CONCLUSIONS: The present study shows that patients with small varices have a low bleeding risk. An increase in Child-Pugh score during follow-up suggests enlargement of varices, thus an increase in bleeding risk. In these patients closer endoscopic surveillance is recommended.

Total and functional hepatic blood flow decrease in parallel with ageing.

OBJECTIVES: To study changes in hepatic blood flow with age. DESIGN: Functional hepatic flow (FHF) and total hepatic flow (THF) were determined by non-invasive methods in 40 normal subjects in four age groups (<45, 45-60, 61-75 and >75 years). All subjects had normal routine liver function tests and no history of liver disease. RESULTS: THF was measured by pulsed echo-Doppler, as the sum of portal and hepatic artery blood flow; FHF was measured by the hepatic clearance of D-sorbitol. THF significantly decreased with age, particularly in subjects over 75 (from 1445+/-220 ml/min to 1020+/-148; P<0.001), and a similar reduction was observed in FHF (from 1514+/-250 ml/min to 1015+/-163; P<0.001). THF and FHF were strictly correlated in the whole population (r = 0.871; P<0.001) and both correlated with age (r = -0.510 and r = -0.596; P<0.005). CONCLUSION: With ageing there is a reduction of hepatic blood flow without any additional intrahepatic shunting.

Prostaglandin E1 infusion and functional hepatic flow in control subjects and in patients with cirrhosis.

Metabolic effects of prostaglandin E1 have been previously demonstrated in cirrhosis, apparently independent of changes in large splanchnic vessel hemodynamics. The effects of prostaglandin E1 on functional liver blood flow were tested by measuring the extrarenal clearance of D-sorbitol in six controls and eight patients with cirrhosis during systemic superinfusion of saline or prostaglandin E1 (30 microg/hr), in random order. Doppler ultrasonography of systemic and splanchnic circulation was also performed before the test and at the end of the two study periods. Prostaglandin E1 infusion increased femoral blood flow by nearly 60% in controls and over 30% in cirrhosis, without any effect on mean arterial pressure and heart rate. Mesenteric artery and portal blood flow were unchanged, as were Doppler-measured resistance indices in the liver, spleen and kidney. Sorbitol-assessed functional hepatic flow was 30% lower in cirrhosis, and did not change systematically during prostaglandin E1 infusion. We conclude that prostaglandin E1, at doses able to elicit metabolic effects and changes in systemic hemodynamics, does not affect splanchnic blood flow and/or hepatic microcirculation in normal subjects and in portal-hypertensive patients with cirrhosis.

Effects of systemic prostaglandin E1 on splanchnic and peripheral haemodynamics in control subjects and in patients with cirrhosis.

Prostaglandins of the E series showed metabolic and clinical effects in patients with liver disease; changes in splanchnic haemodynamics might be involved. Blood flow in femoral and mesenteric artery and in the portal vein was measured by echo-Doppler in 10 controls and 14 cirrhotic patients, in response to the systemic infusion of a PGE1 analogue (30 micrograms/h for 2-6 h) or saline, performed in random order. Intraparenchymal resistive and pulsatility indices in the liver, spleen and kidney were also measured. In both groups PGE1 increased femoral artery flow by 40%, irrespective of infusion time. Heart rate increased slightly, whereas mean arterial pressure decreased. There were no changes in mesenteric artery and portal vein flow, as well as in resistance indices. Saline infusion increased femoral artery flow by 4%. PGE1 infusion does not produces significant effects on Doppler-assessed splanchnic hemodynamics in controls and in cirrhotic patients, in spite of significant effects on peripheral circulation.

Effects of systemic prostaglandin E1 on hepatic amino acid-nitrogen metabolism in patients with cirrhosis.

Prostaglandins of the E (PGE) series have long been considered "catabolic" hormones, but recent data suggest that they may be secreted in critically ill patients to counteract stress hormones, stimulating protein synthesis. Their use is under scrutiny to improve hepatic microcirculation and as cytoprotective agents. We tested the effects of PGE1 on hepatic and whole-body nitrogen metabolism in eight patients with cirrhosis. Urea-nitrogen synthesis rate, alpha-amino-nitrogen levels, and nitrogen exchange were measured in the basal, postabsorptive state and in response to continuous alanine infusion, in paired experiments, during superinfusion of PGE1 or saline. Splanchnic and systemic hemodynamics were assessed by echo-Doppler at the beginning and at the end of each experiment. PGE1 produced a rapid fall in plasma amino acids and in urea-nitrogen synthesis rate, as well as a positive nitrogen exchange. The slope of the regression of alpha-amino-nitrogen levels on urea-nitrogen synthesis rate, a measure of liver cell metabolic activity, was not affected, but the regression line was shifted rightward, suggesting a nitrogen-sparing effect of PGE1. Mesenteric artery and portal flow were unchanged, whereas femoral artery flow increased by 30%. Insulin and glucagon levels were not systematically different. We conclude that PGE1 reduces hepatic urea synthesis rate, independent of hormones and/or hepatic flow, possibly acting at the peripheral level on amino acid transport, thus reducing amino acid supply to the liver. The resulting net nitrogen sparing might be the basis for the beneficial effect of PGE1 in clinical hepatology.

Transient spontaneous regression of hepatocellular carcinoma.

We report on 2 patients with liver cirrhosis and biopsy-proven hepatocellular carcinoma who underwent spontaneous regression. In 1 case the tumor became undetectable at ultrasonography, while, in the other, the liver lesions decreased in size and showed inner calcifications. In both patients, alpha-fetoprotein, which was high at first diagnosis, returned to normal values. After a tumor-free period of 4 years and 17 months, respectively, liver cancer reappeared and patients died from complications. We advance the hypothesis that tumor regression, when it occurs in cirrhotic patients, is always transient, with chronic liver disease being the oncogenic triggering factor.

Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis.

The aim of this study was to prospectively evaluate the usefulness of the Italian Liver Cirrhosis Project (ILCP) classification of esophageal varices, together with the gastric features of portal hypertension, in predicting the first upper gastrointestinal bleeding in cirrhosis. The efficiency of these endoscopic parameters in predicting bleeding was also compared with the efficiency of the North Italian Endoscopic Club (NIEC) index. Three hundred forty-four cirrhotic patients with esophageal varices but without any previous bleeding were enrolled in the study. The following endoscopic parameters of esophageal varices were recorded: location, size, occupancy, blue tone, and red color signs. Gastric varices were graded as absent or present, while congestive gastropathy was considered as absent, mild to moderate, or severe. All patients were followed until the first upper gastrointestinal bleeding and/or death, or for at least 24 months. No patient received any treatment to prevent bleeding. Sixty-five patients bled from the upper gastrointestinal tract during the study. Univariate analysis showed that all endoscopic parameters were predictors of bleeding. According to multivariate analysis (Cox's model), size, gastric varices and congestive gastropathy were the only independent predictors of bleeding, and the following prognostic index (PI) was developed: PI = (size x 0.0395) + (congestive gastropathy x 0.878) + (gastric varices x 0.705). This index, which was validated using a split-sample technique, and which appears to be superior to the NIEC index in predicting bleeding, may be useful in decision making for primary prophylaxis.

Transdermal nitroglycerin in cirrhosis. A 24-hour echo-Doppler study of splanchnic hemodynamics.

BACKGROUND/AIMS: The present study was aimed to evaluate the 24-hour effect of transdermal nitroglycerin on splanchnic hemodynamics in cirrhotic patients. METHODS: Hemodynamic parameters (blood velocity and resistance indexes) were determined by means of pulsed echo-Doppler, a non-invasive method which proved to be useful to evaluate the effects of drugs on splanchnic vessels. Nine patients with biopsy-proven liver cirrhosis were studied. They were kept on a standard diet divided into 3 meals served at 8, 12 a.m. and 6 p.m. Echo-Doppler measurements were determined for 2 consecutive days at 7, 8, 9, 12 a.m, 1, 3, 6, 7, 9, 12 p.m. and again at 7 a.m. A transdermal nitroglycerin tape, capable of releasing 15 mg of the drug in 24 h, was applied to the skin of the chest at 7 a.m. of the second day. RESULTS: After nitroglycerin mean portal blood velocity and flow significantly decreased by 18 and 22%. Similarly superior mesenteric artery velocity decreased, while resistance indexes increased. ANOVA analysis showed a significant effect of the drug on superior mesenteric artery and portal flow, while the effect on hepatic artery flow and renal indexes were low. CONCLUSIONS: This study shows that nitroglycerin, given as transdermal long-acting system, significantly influences portal hemodynamics in liver cirrhosis. Its use, favoured by easy administration, may be proposed for long-term clinical studies to test its efficacy in preventing gastrointestinal bleeding.

Efficacy of a surveillance program for early detection of hepatocellular carcinoma.

BACKGROUND: Contrasting data have so far been reported on the utility and efficacy of screening patients with cirrhosis for early detection of hepatocellular carcinoma (HCC). The goal of this study was to evaluate the efficacy of a regular ultrasonographic and laboratory follow-up for the early detection of small HCC, and to identify parameters correlated with a higher risk of developing HCC. METHODS: One hundred and sixty-four consecutive patients with liver cirrhosis living in Emilia Romagna, Italy, were enrolled in the period 1989-1991. All patients underwent clinical, biochemical, and ultrasonographic evaluations at entry and at 3- and 6-month intervals during follow-up. RESULTS: By April 1995, 34 patients had developed HCC. In 76% of the patients, ultrasonography identified HCC when it was still single and small (< 4 cm). At discriminant, logistic regression and univariate analyses, sex and the entry concentration of alkaline phosphatase, alpha-fetoprotein, gamma-glutamyl transpeptidase, and albumin were associated with a higher risk of developing HCC, whereas at multivariate analysis (Cox's model), only sex and the entry concentration of alkaline phosphatase, albumin, and alpha-fetoprotein were independently and significantly related to the appearance of HCC. CONCLUSIONS: A regular ultrasonographic follow-up, timed at 3- to 6-month intervals according to the risk of HCC development in patients with cirrhosis, allows the detection of liver carcinoma at an early stage in a high proportion of patients, possibly improving the prognosis of the disease.