One-year intense nutritional counseling results in histological improvement in patients with non-alcoholic steatohepatitis: a pilot study

BACKGROUND AND AIM: In individuals with biopsy-proven non-alcoholic steatohepatitis (NASH), short-term weight loss has been shown to improve biochemical abnormalities; however, its effect on liver histology is largely unknown. The aim of the article is to determine if dietary intervention is effective in improving histological features of steatohepatitis in patients with biopsy-proven NASH. METHODS: Twenty-three patients (11M/12F) with BMI >25 kg/m(2) and biopsy-proven NASH received standardized nutritional counseling aimed at reducing insulin resistance (IR) and weight. Blood tests were checked at baseline and every 1-4 months, and liver biopsy was repeated at month 12. IR was assessed by the homeostasis model assessment (HOMA). Liver biopsies were scored according to modified Brunt criteria for NASH. "Histologic response" was defined as a reduction in total NASH score of >/=2 points with at least one point being in the non-steatosis component. RESULTS: Sixteen patients (8M/8F) completed 12 months of dietary intervention, and 15 underwent repeat liver biopsies. At month 12, mean weight decreased from 98.3 to 95.4 kg. Mean waist circumference, visceral fat, fasting glucose, IR, triglycerides, AST, ALT, and histologic score were all reduced but the difference was not significant. Nine patients had a histologic response, six had stable scores, and none had a worsened score. Compared to patients with unchanged histologic scores, patients with improved scores had significantly greater reduction in weight, waist circumference, AST, ALT, steatosis grade, and total NASH score. CONCLUSION: Among patients who successfully completed 1 yr of intense dietary intervention, nine of 15 patients with NASH displayed histologic improvement. This pilot study suggests that dietary intervention can be effective in improving histology in patients with biopsy-proven NASH.     

Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer practice

Fatigue, pain, distress, and anorexia are four commonly encountered symptoms in cancer. To evaluate the usefulness of a single-item screening for these symptoms, 597 ambulatory outpatients with solid tumors were administered a self-report screening instrument within the first 12 weeks of chemotherapy. Patients rated the severity of each symptom on a 0-10 scale, at its worst over the past three days, with higher ratings associated with higher symptom levels. From this sample, 148 patients also completed a more comprehensive assessment of these symptoms. Two criteria were used to determine optimal cut-off scores on the screening items: 1) the sensitivity and specificity of each screening item to predict clinical cases using receiver-operating characteristics analysis and 2) the proportion of patients at each screening score who reported that some relief of the target symptom would significantly improve their life. Optimal cut-off scores ranged from 4 to 6 depending on the target symptom (area under the curve range=0.68-0.88). Use of single-item screening instruments for fatigue, pain, distress, and anorexia may assist routine clinical assessment in ambulatory oncology practice. In turn, such assessments may improve identification of those at risk of morbidity and decreased quality of life due to excess symptom burden.     

The resurgence of syphilis among men who have sex with men

PURPOSE OF REVIEW: To identify recent progress and emerging problems in addressing syphilis among men who have sex with men. RECENT FINDINGS: A resurgence of syphilis has occurred among men who have sex with men in many developed countries. Infection has been associated with HIV coinfection, multiple partners, and recreational drug use. Unlike HIV, oral sex appears to be a common route of syphilis transmission. Many prevention approaches have shown, at best, modest success. Variable clinical presentation and potentially inconclusive lab tests make diagnosis confusing. SUMMARY: As the infection remains relatively rare, clinicians treating men who have sex with men should maintain a high index of suspicion for syphilis lesions, and should screen their sexually active patients for latent disease. Debates about syphilis control and treatment continue. The clinical manifestations, serologic responses, efficacy of treatment, and complications of syphilis have always been complicated. HIV coinfection adds to the confusion.     

Selective elevation of monomeric IgA1 in IgA nephropathy patients with normal renal function

The molecular form of the pathognomonic IgA in IgA nephropathy (IgAN) remains controversial. Because characterization of the molecular form of IgA molecules can lend insight into their origin (systemic v mucosal), we developed immunoassays to measure both total and J chain-containing (polymeric) IgA1 and IgA2. These assays were used to measure IgA in sera from two groups of IgAN patients (with normal or decreased renal function), as well as from a group of normal individuals. IgA1 levels were higher in both groups of patients with IgAN when compared with the controls. The elevation appeared to be restricted to non-J chain-containing (monomeric) IgA1 in patients with normal renal function, whereas polymeric IgA1 was also slightly elevated in patients whose renal function was diminished. While there were no significant differences between the groups in terms of the levels of total IgA2, the patient group with normal kidney function appeared to have lower levels of polymeric IgA2. The observation that the elevation in serum IgA appears to be restricted to the monomeric form of IgA1, at least when renal function is normal, implies a systemic origin of the pathognomonic IgA in IgAN and further suggests an abnormality in the regulation of IgA secretion by immunoglobulin-producing cells in bone marrow, the site of systemic IgA synthesis.     

Endoscopic paranasal sinus surgery: radiographic evaluation of severe complications.

PURPOSE: To report our experience with the radiographic evaluation of severe complications resulting from the functional endoscopic sinus surgery (FESS) procedure. PATIENTS: Ten major complications were reviewed retrospectively. FINDINGS: Ten major complications occurred. Eight of 10 had injury to the floor of the anterior cranial fossa, fovea ethmoidalis (roof of the ethmoid sinus), or roof of the sphenoid sinus. Six patients presented with meningitis or rhinorrhea, two presented with headache and massive pneumocephalus; one patient who presented with meningitis had a large nasal frontal encephalocele. Noncontrast brain CT that included the paranasal sinuses adequately evaluated the source of pneumocephalus. Thin-section coronal CT accurately predicted the site of leak in five patients. Both coronal sinus CT and MR imaging were useful to confirm the nasal encephalocele. Two of 10 had vascular injury secondary to FESS. One patient presented with subarachnoid hemorrhage seen on noncontrast CT and cerebral angiography demonstrated an aneurysm of the anterior cerebral artery. The second patient suffered severe intraoperative hemorrhage. Emergency angiography revealed a pseudoaneurysm of the cavernous carotid artery, and balloon occlusion of the artery was performed. No deaths occurred in this series. CONCLUSION: Radiologists should be familiar with the rare, but potential complications of this commonly performed procedure in order to help direct the work-up in an efficacious manner.     

Expression of ICAM-R (ICAM-3), a novel counter-receptor for LFA-1, in rheumatoid and nonrheumatoid synovium

Objective. To study the distribution of intercellular adhesion molecule receptor (ICAM-R, or ICAM-3), a novel ligand for the leukointegrin lymphocyte function-associated antigen 1 (LFA-1), in normal and rheumatoid synovial membranes and to compare this with the distribution of ICAM-1, ICAM-2, vascular cell adhesion molecule 1 (VCAM-1), and endothelial leukocyte adhesion molecule 1 (ELAM-1). Methods. We performed immunohistochemical analyses of frozen sections of normal and rheumatoid synovial tissue using monoclonal antibodies to the molecules examined. Results. ICAM-1 staining was detectable on the vascular endothelium and the synovial lining cells of both normal and rheumatoid synovial membranes. A variable proportion of lymphocytes infiltrating rheumatoid tissues expressed ICAM-1. ICAM-2 staining was demonstrable in the vascular endothelium of both normal and inflamed tissues, the latter demonstrating a significantly higher proportion of positive vessels. ELAM-1 staining was not detectable in normal synovial membranes but was seen on the endothelium of a limited number of rheumatoid synovial vessels, usually close to the synovial lining cell layer. VCAM-1 staining was intense in both normal and rheumatoid synovial lining cells, but vascular staining was weak in both. In contrast, ICAM-R staining was not detected in association with any synovial blood vessels, but was widely expressed by lymphocytes and macrophages. Cells of the lining layer did not stain for ICAM-R. Conclusion. Although ICAM-R is a ligand for LFA-1 and shares considerable sequence homology with ICAM-1 and ICAM-2, it does not appear to be expressed by the endothelium of normal or inflamed synovial vessels. Intense expression of ICAM-R by rheumatoid synovial lymphocytes and macrophages suggests that it may play a role in processes requiring cell-cell contact, such as antigen presentation and homotypic aggregation.