Federico Lari

Coeliac disease hidden by cryptogenic hypertransaminasaemia

BACKGROUND Hypertransaminasaemia of unknown, cryptogenic, origin occasionally has been found to be the only sign of coeliac disease. Raised concentrations of transaminases, or aminotransferases, have been retrospectively observed in about a half of patients with coeliac disease who are on a gluten-containing diet. We aimed to establish the overall prevalence of coeliac disease among patients with cryptogenic hypertransaminasaemia. METHODS Of the 600 consecutive patients referred to our outpatient clinic for liver disease due to raised serum transaminases from September, 1995, to June, 1997, 55 were classified as having cryptogenic hypertransaminasaemia after the exclusion of every known cause of liver disease. These patients were tested by indirect immunofluorescence for IgA to endomysium and for IgA and IgG to gliadin. FINDINGS Five patients were positive for both IgA to endomysium and IgG to gliadin, whereas IgA to gliadin was only found in four patients. IgG to gliadin was also present in another patient who was not positive for antibodies to endomysium. The six antibody-positive patients had duodenal biopsy that showed a subtotal villous atrophy consistent with coeliac disease in the five patients with antibodies to endomysium. The patient with only IgG to gliadin had a normal small-intestine mucosa. None of the five patients with coeliac disease had gastrointestinal symptoms. Liver biopsy samples were taken from three of the five patients with flat mucosa and showed a histological picture of nonspecific reactive hepatitis. Transaminase concentrations reverted to normal within 6 months in four patients with coeliac disease who followed a strict gluten-free diet. INTERPRETATION Our results show that about 9% of patients with cryptogenic hypertransaminasaemia are affected by symptom-free coeliac disease. Gluten-sensitive enteropathy and antibody screening for coeliac disease by means of antibodies to endomysium and gliadin should be considered in these patients.

La ventilazione meccanica non invasiva nell’insufficienza respiratoria acuta: stato dell’arte (II parte)

Summary Background: In the last years Non-Invasive Ventilation (NIV) has been playing an important rolein the treatment of Acute Respiratory Failure (ARF). A lot of trials have shown improvements in clinical features (respiratory rate, neurological score), pH and arterial blood gases. Methods: In particular clinical conditions, such as Acute Cardiogenic Pulmonary Edema (ACPE) and acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), systematic reviews and meta-analysis show a reduction in the need for intubation and in-hospital mortality compared to standard medical treatment. In other clinical conditions, such as acute asthma, Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS) and severe pneumonia, NIV does not show significant improvements in term of avoided intubations or mortality rate. Although the first important data on NIV comes from studies performed in Intensive Care Units (ICUs), subsequently these methodologies of ventilation have been used with increasing frequency in Emergency Departments (ED) and medical wards. Results: Studiesdeveloped inICU sometimes report slightly worse outcomes compared to studies performed in general wards due to the need to treat more severe patients in ICU. Aetiology remains one of the most important factor determining prognosis: different pathological mechanisms substain different clinical conditions and not in all cases the application of positive

Noninvasive ventilation for acute respiratory failure: state of the art (II part)

Background: In the last years Non-Invasive Ventilation (NIV) has been playing an important role in the treatment of Acute Respiratory Failure (ARF). A lot of trials have shown improvements in clinical features (respiratory rate, neurological score), pH and arterial blood gases. Methods: In particular clinical conditions, such as Acute Cardiogenic Pulmonary Edema (ACPE) and acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD), systematic reviews and meta-analysis show a reduction in the need for intubation and in-hospital mortality compared to standard medical treatment. In other clinical conditions, such as acute asthma, Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS) and severe pneumonia, NIV does not show significant improvements in term of avoided intubations or mortality rate. Although the first important data on NIV comes from studies performed in Intensive Care Units (ICUs), subsequently these methodologies of ventilation have been used with increasing frequency in Emergency Departments (ED) and medical wards. Results: Studies developed in ICU sometimes report slightly worse outcomes compared to studies performed in general wards due to the need to treat more severe patients in ICU. Aetiology remains one of the most important factor determining prognosis: different pathological mechanisms substain different clinical conditions and not in all cases the application of positive pressures to the airways is useful. NIV for ARF due to COPD and ACPE is feasible, safe and effective also in a general medical ward if selection of patients, staff training and monitoring are appropriate: its early application improves clinical parameters, arterial blood gases, prevents endotracheal intubation, decreases mortality and hospitalisation. This should encourage the diffusion of NIV in this specific setting.

Non-invasive mechanic ventilation in treating acute respiratory failure

Non invasive ventilation (NIV) in acute respiratory failure (ARF) improve clinical parameters, arterial blood gases, decrease mortality and endo tracheal intubation (ETI) rate also outside the intensive care units (ICUs). Objective of this study is to verify applicability of NIV in a general non respiratory medical ward. We enrolled 68 consecutive patients (Pts) with Hypoxemic or Hyper capnic ARF: acute cardiogenic pulmonary edema (ACPE), exacerbation of chronic obstructive pulmonary disease (COPD), Pneu - monia, acute lung injury / acute respiratory distress syndrome (ALI/ARDS). NIV treatment was CPAP or PSV + PEEP. 12 Pts (18,5%) met primary endpoint (NIV failure): 11 Pts (17%) needed ETI (5ALI/ARDS p < 0,0001, 6COPD 16,6%), 1 Patient (1,5%) died (Pneumonia). No Pts with ACPE failed (p = 0,0027). Secondary endpoints: significant improvement in Respiratory Rate (RR), Kelly Score, pH, PaCO2, PaO2 vs baseline. Median duration of treatment: 16:06 hours: COPD 18:54, ACPE 4:15. Mean length of hospitalisation: 8.66 days. No patients discontinued NIV, no side effects. Results are consistent with literature. Hypoxemic ARF related to ALI/ARDS and pneumonia show worst outcome: it is not advisable to manage these conditions with NIV outside the ICU. NIV for ARF due to COPD and ACPE is feasible, safe and effective in a general medical ward if selection of Pts, staff’s training and monitoring are appropriate. This should encourage the diffusion of NIV in this specific setting. According to strong evidences in literature, NIV should be considered a first line and standard treatment in these clinical conditions irrespective of the setting.

PEEP in non invasive ventilatory treatment of worsened BPCO

Acute respiratory failure due to exacerbation of chronic pulmonary disease is usually treated with bilevel pressure non invasive ventilation. An high inspiratory pressure is used to improve tidal volume, a lower expiratory pressure is used to neutralize end expiratory positive pressure of patient (PEEPi) caused by flow limitation and airway trapping. When ventilators for bilevel pressure ventilation are not available, is useful to administer to patient an external low (5cmH2O) positive pressure with simple CPAP systems (Continuous Positive Airway Pressure, such as Venturi like flow generator) largely available and well known everywhere.