The selection criteria in liver transplantation for HCC are a matter of debate. We reviewed our series, comparing two periods: before and after 1996, when we started to apply the Milan criteria. The study population was composed of patients with a preoperative diagnosis of HCC, confirmed by the pathological report and with a survival of >1 year. Preoperative staging as revealed by radiological imagining was distinguished from postoperative data, including the variable of tumor volume. After 1996 tumor recurrences significantly decreased (6 out of 15 cases, 40% vs. 3 out of 48, 6.3%, P < .005) and 5-year patient survival improved (42% vs. 83%, P < .005). Not meeting the Milan criteria was significantly related to higher recurrence rate (37.5% vs. 12.7%, P < .05) and to lower 5-year patient survival (38% vs. 78%, P < .005%) in the preoperative analysis, but not in the postoperative one. The alfa-fetoprotein level of more than 30 ng/dL and the preoperative tumor volume of more than 28 cm 3 predicted HCC recurrences in the univariate and mutivariate analysis (P < .005 and P < . S ince liver transplantation (LT) was first proposed for patients with hepatocellular carcinoma (HCC), three distinct periods can be identified. In the first there was no patient selection and the results obtained were disappointing. 1 -3 In 1996, the Milan criteria (MC) were proposed 4 and gradually included in the selection options of liver transplant centers, with remarkably improved results. Unfortunately, many patients do not meet the MC and are excluded from any therapeutic strategy. This is the main reason why some authors suggest that these criteria should be expanded. 5,6 Several papers have appeared in the literature, including results obtained with patients transplanted because of HCC and not meeting the MC. In these reports, the authors included postoperative (post-op) tumor features in their analysis, which have a substantial chance of being different from the preoperative (pre-op) evaluation. 4,6 -14 At the time of inclusion on the waiting list for LT, the possibility of predicting HCC recurrence in the individual patient is usually evaluated by the MC, which only include the number and diameter of the HCC, since other HCC biological features have not proven to be of clinical usefulness. 15 The introduction of selection criteria based on these parameters has led to a rate of tumor recurrence (TR) lower than 20%, but these criteria envisage only two groups of patients: a low risk of TR after LT and a risk which is not low. The clinicopathological variables related to the outcome of LT are multiple and a more specific scoring system to assay the risk of TR is advisable. We retrospectively reviewed our series focusing on the bias between pre-op and post-op data and investigating the variables effective in adding a specific risk of TR to patients after LT. Materials and Methods Study PopulationFrom November 1986 to August 2001, 657 LTs were performed at the Department of Surgery and Transplantation of the University of Bologna. O...
I read with interest the article by Pakpoor and colleagues investigating the risk of hospital admission for multiple sclerosis (MS) after admission for testicular hypofunction. 1Although interesting, the study is far from proving a causal effect of testicular hypofunction on MS risk. Given that there is a negative age-adjusted correlation with testosterone levels and disability, 2 it would be interesting if the authors couldshow that the patients with admissions for testicular hypofunction and then MS did not have any admissions that could be related to MS prior to the testicular hypofunction admission. Furthermore, it would also be of interest to see the risk for testicular hypofunction admission after being admitted for MS. Depending on the results of these investigations, this would shed further light on a causal or consequential role of testosterone in MS. Potential Conflicts of InterestNothing to report. We thank Dr Voci for his comments on our article reporting that male subjects with testicular hypofunction (TH) have a 5-fold higher rate of subsequent multiple sclerosis (MS). The possibility of reverse causality whereby MS may cause TH is an important consideration. However, in all the cases reported by us, the time lapse between the first episode of day-case care or hospital admission for MS occurred at least 1 year after the first episode of day-case care or hospital admission for TH, making a reverse sequence of events unlikely. Furthermore, using the same methodology and reference cohort as in our original study, we analyzed the data set for the risk of TH following an admission for MS. The rate ratio was 1.07 (95% confidence interval 5 0.43-2.2, p 5 0.98), based on 7 observed and 6.6 expected cases.Dr Voci also felt it important that we demonstrate that patients admitted with TH who were subsequently admitted for MS did not have any prior admissions that could have been related to MS. We agree with Dr Voci and, in our article, we did this by excluding all subjects from the TH cohort who had any episode of day-case care or admission for MS at the same time as, or before, their first admission for TH. In the data here, on MS before TH, a concurrent or previous admission for TH before MS was excluded, thus ensuring that in considering both analyses (TH before MS, and MS before TH) no one was double-counted. Repeating our study using other diagnoses, symptoms, or signs suggestive of MS prior to TH would be a complex undertaking given the considerable variety of ways in which MS can present.We hope our study of an association between TH and subsequent MS stimulates further work to confirm or refute our findings. We cannot establish causation, which would require a different study design, but our findings are consistent with a hypothesis that supports a role for low testosterone levels in the complex causative cascade underlying MS.
This is the case of a 76-year-old man admitted to hospital in a delirium state, previously diagnosed with a major depressive disorder at an age of 50 years, treated for years for chronic tension headache. The computed tomography of the head resulted negative. Inpatient laboratory tests revealed a mild hypercalcemia. Due to the progression of the disease (delirium state, dementia, tension headache, and depression), he was again admitted to hospital. The patient showed dysarthria, postural tremors, mirror movements and palmar hyperhidrosis, mild ataxia when walking, and rigidity. Sleep disturbances were also observed. He underwent several clinical diagnostic tests, which resulted negative. After more than 2 years, the ultrasound of the neck identified enlarged parathyroid glands. The patient was surgically treated, and three parathyroid glands were removed. Parathyroidectomy and lithium treatment resulted in improvement of cognitive functions. In elderly patients, concomitant presence of cognitive dysfunction may mask the underlying primary hyperparathyroidism.
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