Search

Digestive endoscopy is the most effective tool available for the diagnosis of multiple gastrointestinal (GI) tract conditions, and it represents a key aspect in the training of gastroenterology residents according to the Spanish MIR (medico interno residente) program. The Sociedad Espanola de Endoscopia Digestiva (SEED), aware of all the technical advances that have emerged during the past few years, deems it necessary to define a program of the skills specialists-in-training in gastroenterology should acquire during their residency. This paper describes the goals of endoscopy training, the techniques that should be mastered, and the diagnostic and therapeutic skills this specialty requires. Finally, a model is suggested for the assessment of competence.

The development of minimally invasive procedures has rekindled interest in endoluminal techniques for the management of Zenker's diverticulum. Tissue sealers as employed in laparoscopic surgery have not been previously used for Zenker's diverticulum septotomy.Supported by the established safety of linear cutters, bipolar forceps, and ultrasonic scalpels, we have started a procedure using the Ligasure 5™ tissue sealer. Safety and efficacy results in our early clinical experience are shown for a prospective series of 5 consecutive Zenker's diverticulum cases that were perorally managed with tissue sealing.The procedure was quickly and safely performed in the endoscopy room under sedation. Mean number of seals per patient was 2, and mean procedure duration was 33 minutes. No complications developed during or after the procedure, and patients were discharged with immediate dysphagia relief and adequate oral tolerance. No diverticular relapses occurred after a mean follow-up of 21 months (range 18-30). This procedure may be repeated as often as desired with no need for hospital admission. Safety should be prospectively assessed by further studies using a higher number of procedures.

Background and aims: Malignant gastric outlet obstruction can be treated by means of enteral stenting or surgical gastrojejunalanatomosis. We evaluated in a prospective and multicentre study the efficacy of the enteral stent on food intake, the quality of life impact, and the relationship between efficacy and determined clinical and technical parameters. Patients and methods: Seventy one patients affected by symptoms arising from gastroduodenal obstruction due to malignant tumors, with criteria of irresecability, metastatic disease or very high surgical risk, were treated by means of self expanding metal stents. We used the GOOSS index to evaluate efficacy, and the Euro Qol-5D index to evaluate quality of life. Results: Before stenting patients with GOOSS 0 and 1 were 68 (98.5%). After stenting patients with GOOSS 2 and 3 (semisolid and solid food) were 58 (84,1%) (P

Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. It is not yet possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids, a fusion of minilaparoscopy and transluminal endoscopic surgery. In this paper we present a prospective clinical series of 15 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis.This was a prospective clinical series of 15 consecutive female patients, nonrandomly chosen and without a control group, who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two entryways for cholelithiasis. One was umbilical and measured 5 mm in diameter, and the other was in the right upper quadrant and measured 3 mm in diameter.The scheduled surgical intervention was performed on the 15 patients in whom it had been indicated. There were no intraoperative complications. One patient had mild hematuria that resolved in less than 12 h; there were no other complications after average follow-up of 124 days. Nine patients were discharged in 24 h, and two were discharged less than 12 h after the procedure.Hybrid transvaginal cholecystectomy is a good surgical model for minimally invasive surgery, a combination of NOTES and minilaparoscopy. It can be performed in surgical settings where laparoscopy is practised regularly, using the instruments normally used for endoscopy and laparoscopic surgery. Owing to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future.

Background & Aims: Mismatch repair (MMR) deficiencies are the hallmark of tumors arising in Lynch syndrome, however, in approximately 15% of sporadic colorectal cancers (CRC) these deficiencies most often are associated with somatic methylation of the MMR gene MLH1. Recently, an oncogenic mutation in the BRAF gene has been involved in sporadic CRC showing MMR deficiencies as a result of MLH1 promoter methylation. The aim of this study was to evaluate the contribution of BRAF V600E mutation analysis in the identification of MSH2/MLH1 gene mutation carriers in newly diagnosed CRC patients. Methods:BRAF V600E mutation was analyzed in CRC patients with MMR deficiencies (microsatellite instability and/or lack of MLH1/MSH2 protein expression) in the EPICOLON population-based study. The effectiveness and efficiency of different strategies were evaluated with respect to the presence of MSH2/MLH1 germline mutations. Results: MMR deficiencies were detected in 119 of the 1222 CRC patients with tumors showing either microsatellite instability (n = 111) or loss of protein expression (n = 81). BRAF mutation was detected in 22 (18.5%) of the patients. None of the patients with unambiguous germline mutation had BRAF mutation. Regardless of the strategy used to identify MSH2/MLH1 gene carriers, the introduction of BRAF analysis in these patients slightly improves their effectiveness. The introduction of BRAF mutation analysis as a step before germline genetic testing in patients with MMR deficiencies achieved a significant reduction in costs per mutation detected. Conclusions: Detection of BRAF V600E mutation could simplify and improve the cost effectiveness of genetic testing for hereditary nonpolyposis colorectal cancer, especially in patients whose family history is incomplete or unknown.

[Background and Aims]: Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior., [Methods]:This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery., [Results]: The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome., [Conclusions]: An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.

Introduccion La colitis ulcerosa es una enfermedad inflamatoria cronica que afecta a algun tramo o a la totalidad del colon. Desde el punto de vista endoscopico, la colitis ulcerosa presenta lesiones que se extienden desde el recto hasta un segmento variable del colon, de forma continua, siendo esta caracteristica de gran valor para diferenciarla de la enfermedad de Crohn. La afeccion ininterrumpida sin tramos indemnes interpuestos justifica que no se prolongue el examen endoscopico, una vez superado el extremo distal de la lesion. Objetivo Estudiar retrospectivamente la frecuencia de lesiones segmentarias en las colonoscopias practicadas a pacientes con colitis ulcerosa. Pacientes y metodos El diagnostico de colitis y proctitis ulcerosa se establecio mediante criterios clinicos, endoscopicos, histologicos, analiticos y radiologicos. La indicacion y el numero de endoscopias obedecio a criterios clinicos de diagnostico, reagudizacion, refractariedad o cribado de displasia. La extension del examen respondio, igualmente, a criterios clinicos: la gravedad del brote, la tolerancia a la colonoscopia o el grado de limpieza. Resultados Se realizo un total de 155 colonoscopias; en 113 (73%) se supero el extremo distal de la lesion, y en 70 (45%) se alcanzo el ciego; 27 de los 80 pacientes (33%) presentaban proctitis ulcerosa en el momento del diagnostico; 9 de los 80 pacientes (11,3%), 7 varones (49,1 ± 21,55 anos) y 2 mujeres (45 ± 20,52 anos) presentaron lesiones endoscopicas segmentarias, interponiendo tramos endoscopicamente sanos con otros lesionados. Las biopsias sobre todos los segmentos lesionados confirmaron la afeccion. Sobre los tramos interpuestos sanos se realizaron biopsias en 3 de los 9 pacientes que confirmaron la indemnidad microscopica; 6 de los 9 pacientes no recibian ningun tipo de tratamiento. En todos los pacientes, excepto en 2, se alcanzo el ciego en alguna de las colonoscopias. La distribucion de las lesiones segmentarias fue variable, pero predomino la lesion segmentaria periapendicular y en ciego en 6 de los 7 pacientes en que se alcanzo el ciego. Cinco de los 80 pacientes (6,3%) presentaron el recto respetado endoscopicamnete, y cuatro de ellos recibian tratamiento sistemico o topico. El analisis histologico confirmo la ausencia de lesiones inflamatorias en todos ellos. El unico paciente que no tomaba ningun tratamiento presento lesiones microscopicas compatibles con colitis ulcerosa. Conclusiones La lesion endoscopica segmentaria en la colitis ulcerosa aparecio en un 11,3% de los pacientes. El ciego y la region periapendicular son los tramos que con mayor frecuencia albergan lesiones segmentarias. La indemnidad rectal endoscopica y microscopica puede ser el resultado del tratamiento sistemico o topico.

Submucosal chromoendoscopy involves the injection of a solution containing a vital stain, usually indigo carmine, into the intestinal wall submucosal layer. This allows to: Better delimit and characterize the various epithelia present (colonic mucosa, adenoma, hyperplastic polyp, serrated polyp, small bowel mucosa); expose and delimit lesion implantation areas; cooperate in the lifting of resectable lesions; ensure section across the submucosal plane; identify intestinal wall structures; render complex polypectomy feasible; and facilitate the identification of perforations. The present paper offers information on the endoscopic technique for submucosal injection, solution preparation and concentration, and on the potential benefits it may provide for polypectomy or endocopic mucosal resection whether en block or piecemeal. This endoscopic technique simultaneously combines a diagnostic and a therapeutic aspect, since lesion lifting in association with better delimited contours may improve not only accuracy but also endoscopic resection safety and feasibility.

Liver test abnormalities following disulfiram therapy are common. However, overt disulfiram-induced hepatitis is rare but has a high mortality rate, specially when the etiologic role of disulfiram is not suspected and treatment is not discontinued. We report four cases of disulfiram-induced acute hepatitis with different degrees of severity and review the cases reported in the literature. The clinical spectrum of disulfiram hepatotoxicity ranges from minor elevation of serum aminotransferases to fulminant hepatitis. Although some patients with disulfiram-induced hepatitis have manifestations of hypersensitivity, recent clinical and experimental data suggest that disulfiram hepatotoxicity is produced by the accumulation of toxic metabolites.

BACKGROUND: Colorectal cancer (CRC) is the second cause of cancer-related death in the Western world. Much of the CRC genetic risk remains unidentified and may be attributable to a large number of common, low-penetrance genetic variants. Genetic linkage studies in CRC families have reported additional association with regions 9q22-31, 3q21-24, 7q31, 11q, 14q and 22q. There are several plausible candidate genes for CRC susceptibility within the aforementioned linkage regions including PTCH1, XPA and TGFBR1 in 9q22-31, and EPHB1 and MRAS in 3q21-q24. METHODS: CRC cases and matched controls were from EPICOLON, a prospective, multicentre, nationwide Spanish initiative, composed of two independent phases. Phase 1 corresponded to 515 CRC cases and 515 controls, whereas phase 2 consisted of 901 CRC cases and 909 controls. Genotyping was performed for 172 single-nucleotide polymorphisms (SNPs) in 84 genes located within regions 9q22-31 and 3q21-q24. RESULTS: None of the 172 SNPs analysed in our study could be formally associated with CRC risk. However, rs1444601 (TOPBP1) and rs13088006 (CDV3) in region 3q22 showed interesting results and may have an effect on CRC risk. CONCLUSIONS: TOPBP1 and CDV3 genetic variants on region 3q22 may modulate CRC risk. Further validation and meta-analysis should be undertaken in larger CRC cohorts. British Journal of Cancer (2011) 105, 870-875. doi: 10.1038/bjc.2011.296 www.bjcancer.com Published online 2 August 2011, We are sincerely grateful to all patients participating in this study who were recruited in 25 (EPICOLON 1) and 14 (EPICOLON 2) Spanish hospitals as part of the EPICOLON project. We are also grateful to the Spanish National Genotyping Center (CEGEN-ISCIII)-USC and UPF nodes, and the Genome Analysis Platform of the CIC-BioGUNE. The work was carried out (in part) at the Esther Koplowitz Centre, Barcelona. SC-B, CF-R and MDG are supported by contracts from the Fondo de Investigacion Sanitaria (CP 03-0070 to SC-B, CM10/00084 to MDG, and PS09/02368 to CF-R). JM is supported by a contract from the CIBERehd. Both CIBERehd and CIBERER are funded by the Instituto de Salud Carlos III. This work was supported by grants from the Fondo de Investigacion Sanitaria/FEDER (06/1384, 08/0024, 08/1276, PS09/02368, 10/00918), Instituto de Salud Carlos III (Accion Transversal de Cancer), Xunta de Galicia (07PXIB9101209PR), Ministerio de Ciencia e Innovacion (SAF2010-19273), Asociacion Espanola contra el Cancer (Fundacion Cientifica y Junta de Barcelona), Fundacio Olga Torres (SCB and CRP) and FP7 CHIBCHA Consortium (LC-C, ACar and SC-B).

Background & Aims Ten common low-penetrant genetic variants have been consistently associated with colorectal cancer (CRC) risk; little is known about the correlation between these variants and CRC phenotype. Characterization of such a correlation would improve CRC management and prevention programs. We assessed the association between these genetic variants and CRC phenotype in patients and modeled pairwise combinations to detect epistasis. Methods The validation population corresponded to a prospective, multicenter, population-based cohort (EPICOLON I) of 1096 patients with newly diagnosed CRC. The replication set was an independent, prospective, multicenter Spanish cohort (EPICOLON II) of 895 patients with newly diagnosed CRC. For individual single nucleotide polymorphism (SNP) association analyses, a multivariate method using logistic regression was applied in EPICOLON I and subsequently prospectively validated in EPICOLON II. Interactions between SNPs were assessed using the likelihood ratio test. Results Validated results confirmed that the C allele on 8q23.3 (rs16892766) was significantly associated with advanced-stage tumors (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.15–1.90; P value=4.9 × 10 −3 ). The G allele on 8q24.21 (rs6983267) was more common in patients with a familial history of CRC (OR, 2.02; 95% CI, 1.35–3.03; P value=3.9 × 10 −4 ). The combination of rs6983267 on 8q24.21 and rs9929218 on 16q22.2 was associated with a history of colorectal adenoma (carriers of GG and AA, respectively; OR, 2.28; 95% CI, 1.32–3.93; P = 5.0 × 10 −4 ). Conclusions CRC susceptibility variants at 8q23.3, 8q24.21, and 16q22.2 appear to be associated with cancer phenotype. These findings might be used to develop screening and surveillance strategies.

Synovial sarcoma (SS) is an uncommon malignant neoplasm of the soft tissues. It mainly affects the periarticular tissues of the extremities in young adults, but has been described at nearly all sites; nevertheless, the gastrointestinal tract is an exceptional location. We report a case of a primary synovial sarcoma of the duodenum in a 69-year-old woman. Histological study showed a monophasic pattern. The tumor cells demonstrated diffuse vimentin and Bcl-2 expression, partial EMA expression and focal AE1/3 positivity. The differential diagnosis includes gastrointestinal stromal tumors. Cytogenetic analysis confirmed the diagnosis, with detection of the X;18 translocation. The patient presented postoperative complications and died one month following the intervention.

Objective: to report on the first liver resection performed on a human being by a transvaginal NOTES approach combined with minilaparoscopy. Patients and methods: a sixty-one-year-old woman with a his tory of Wertheim’s hysterectomy for endometrial carcinoma 10 years ago, and malignant melanoma correctly treated in 2006, had suspected segment-V liver metastasis near the gallbladder by CTscan and MRI. The indication for a laparoscopic approach was made, and a combined transvaginal and minilaparoscopic resection was offered and accepted by the patient. The procedure was per formed by a multidisciplinary team composed of surgeons and gas troenterologists. It involved creating a pneumoperitoneum by plac ing a Veres needle in the umbilical fundus, followed by the insertion of a 5-mm trocar. A second, 3-mm trocar was placed in the right upper quadrant. A lot of pelvic adhesions were found in the major pelvis, and it was necessary to place a third, 5-mm trocar in the left abdominal side. It was employed only for the adhesions, not for liv er resection. Adhesions were removed to reveal the minor pelvis and the vaginal fornix. A colpotomy was performed with a 12-mm trocar placed inside the vagina, which allowed the insertion of the videogastroscope as far as the liver hilum. Results: liver resection (segment-V partial resection) and chole cystectomy were performed by using a combination of working tools inserted through the entry port for the minilaparoscopy and the videogastroscope. The en bloc resection was removed trans vaginally through the videogastroscope. There were no postopera tive complications, and the patient was discharged after 48 hours. Conclusions: transvaginal liver resection is possible and safe when performed by a multidisciplinary team. Natural orifice trans luminal endoscopic surgery (NOTES) is an emerging modality that seeks to be less invasive, better tolerated, and more respectful of esthetics. It will probably open the way for very important medical and technological innovations.

Objetivo: comunicar la primera colecistectomía transvaginal realizada en humanos en nuestro país. Pacientes y métodos: mujer de 35 años de edad con historia de cólicos hepáticos de repetición de etiología litiásica. La intervención la realizó un equipo multidisciplinar constituido por cirujanos, gastroenterólogos y ginecólogos. Consistió en crear un neumoperitoneo mediante una aguja de Veres colocada en el fondo umbilical con posterior colocación de un trócar de 5 mm. Se colocó un segundo trócar de 3 mm en el hipocondrio derecho. Se realizó una colpotomía y colocación de un trócar vaginal de 12 mm que permitió el paso de un videogastroscopio que alcanzó el hilio hepático. Resultados: se realizó la colecistectomía mediante la acción conjunta de instrumentos de trabajo que pasaron por las puertas de entrada de la minilaparoscopia y por el videogastroscopio. La extracción de la vesícula se realizó por vía transvaginal mediante el videogastroscopio. No aparecieron complicaciones postoperatorias siendo la paciente dada de alta al cabo de 24 horas. Conclusiones: la colecistectomía transvaginal mediante la acción conjunta de un equipo multidiscliplinar es posible y segura. La cirugía endoscópica transluminal a través de orificios naturales (NOTES), es una modalidad emergente que intenta ser menos invasiva, mejor tolerada y más respetuosa con el daño estético que la cirugía laparoscópica y probablemente será la puerta de entrada de innovaciones médicas y tecnológicas de gran trascendencia durante los próximos años.

Sr. Director: El interferon-alfa y la ribavirina han demostrado claramente su eficacia en el tratamiento de la hepatitis C en estudios controlados, y su uso se ha extendido en los ultimos anos1. Sin embargo, presentan efectos secundarios importantes y frecuentes, tanto somaticos como psiquicos2. Los mas habituales entre estos ultimos son los sintomas depresivos y ansiosos, siendo mucho mas raros los psicoticos y maniformes3. Esta muy bien establecido que el uso de psicofarmacos es muy importante de cara a maximizar la adherencia en pacientes con hepatitis C cronica que desarrollan sindromes psicopatologicos durante los meses de tratamiento4,5,6,7. Sin embargo, hay pocos estudios sobre la evolucion de estos trastornos mentales y algunos autores senalan que una parte de ellos podria persistir a lo largo del tiempo, manteniendose la necesidad de tratamiento psiquiatrico continuado6,8,9. Por otro lado, no hemos encontrado datos en la bibliografia sobre incidencia de consumo a largo plazo de psicofarmacos en estos pacientes, especialmente de benzodiacepinas que tienen problemas de manejo a medio y largo plazo. Este punto es especialmente relevante, dado que un porcentaje muy importante de pacientes con hepatitis C tiene antecedentes de abuso de drogas2,3,4. En este trabajo nos planteamos comprobar si el porcentaje de pacientes que toman antidepresivos y ansioliticos 5 anos despues del inicio del tratamiento de la hepatitis C es mayor que el de antes de iniciarlo. Para ello estudiamos retrospectivamente todos los casos de pacientes con hepatitis C que habian seguido tratamiento con interferon-alfa y ribavirina en los ultimos 8 anos en el Hospital...

Objetivo Evaluar la eficacia de las protesis entericas en el tratamiento de la obstruccion gastroduodenal por neoplasias irresecables o inoperables. Estudiar el efecto de este tratamiento sobre la calidad de vida y la supervivencia. Determinar los factores que influyen sobre la eficacia y las complicaciones. Pacientes Se incluyeron 77 pacientes, en 6 no fue posible colocar la protesis. En los 71 restantes (31 varones, 40 mujeres), tenian una edad de 73,10±12,4 anos. El caracter de la indicacion fue: definitiva 63,4%, adyuvante con quimioterapia 35,2% y puente a la cirugia: 1,4%. El indice de Karnofsky fue 64,86±12,9. Metodos Se utilizaron protesis metalicas descubiertas expandibles: Wallflex 76,1%, Wallstent 16,9%, Ultraflex 7% (Boston Scientific). Se colocaron mediante control combinado endoscopico-radiologico en 50,7% y endoscopico unicamente en 49,3% de los casos. Se utilizo el indice clinico GOOSS para valorar la eficacia de la protesis y el cuestionario EuroQol-5D para determinar la calidad de vida. Resultados Localizacion de la obstruccion fue: gastrica 25,4%, duodenal 53,5%, anastomosis quirurgica 21,1%. El tiempo empleado en la colocacion fue 20,49±8,6 min. La duracion del ingreso hospitalario fue 3,3±3,4 dias. Los sintomas de obstruccion gastroduodenal medidos mediante el GOOSS mejoraron al menos 2 puntos en 57 pacientes (p Conclusiones Las protesis entericas son eficaces en la paliacion de la obstruccion al vaciamiento gastrico en la neoplasica gastroduodenal, aunque no mejoran la calidad de vida. La localizacion antral-gastrica de la lesion se relaciona con una menor eficacia. La colocacion sin control radiologico consigue tasas similares de funcionalidad y seguridad, aunque requiere mayor numero de dilataciones previas.

Carbohydrate-deficient transferrin (CDT) has been proposed as a marker of alcohol abuse. However, its value in patients with associated liver disease is still controversial. The aim of the study was to investigate the usefulness of CDT as a marker of alcohol consumption in patients with liver disease. We measured serum levels of CDT and those of commonly used hematological and biochemical markers, mean corpuscular volume (MCV), transaminases (AST and ALT), and gamma-glutamyltransferase in 179 male subjects divided into four groups: 45 active drinkers (13 with normal liver, 21 with fibrosteatosis, and 11 with liver cirrhosis), 45 abstinent chronic alcoholics (18 with and 27 without liver disease), 58 patients with nonalcoholic liver disease, and 31 healthy controls. Serum CDT in active alcoholics was 37.5 +/- 3.6 units/liter, being significantly higher than that of abstinent alcoholics (20.3 +/- 1.5 units/liter), patients with nonalcoholic liver disease (18.1 +/- 1.1 units/liter), and controls (13.1 +/- 0.8 units/liter). Contrary to the other markers, no significant differences were observed in CDT values in relation with the presence and severity of liver disease in either the active drinkers or in the abstinent alcoholics. The sensitivity and specificity of CDT as a marker of alcoholism in the series as a whole was 64% and 82%, respectively, similar to the best conventional marker, MCV (64 and 82%). In patients with liver disease, CDT maintained good sensitivity (72%) and specificity (83%). Receiver operating characteristic analysis confirmed that CDT had a similar diagnostic value to that of MCV, but better than gamma-glutamyl-transferase and transaminases for the detection of alcohol abusers. The good diagnostic efficacy of CDT remained unchanged when analyzing only patients with liver disease. We conclude that serum CDT is a good marker of alcoholism and is less influenced than the currently used biochemical markers for associated liver disease. Thus, CDT is an effective laboratory test to detect alcohol abuse regardless of the presence of alcoholic liver disease.

Investigation by polymerase chain reaction of HBV-DNA in serum from chronic hepatitis B virus carriers is not widely used for routine diagnosis because polymerase chain reaction assays are complex and may be too sensitive. We investigated the sensitivity, the specificity and the possible value for clinical use of a simplified polymerase chain reaction method in which a single, 30 cycles round of polymerase chain reaction is performed using only 10 microliters of serum treated with microwaves. The efficiency of the polymerase chain reaction in amplifying HBV-DNA was greater after microwave irradiation of serum than after alkaline extraction, but lower than after protein digestion and phenol chloroform precipitation. Despite its simplicity and high sensitivity, the assay was very specific. Studies in anti-HBe positive chronic hepatitis B virus carriers demonstrated HBV-DNA sequences in 1/15 (7%) healthy carriers, in 4/20 (20%) patients with slight alanine aminotransferase elevation, in 16/18 (89%) with marked alanine aminotransferase elevation and in all 20 with fluctuating alanine aminotransferase levels. In the latter, HBV-DNA was detected either at exacerbation (two cases), during remission (one case) or both (17 cases). HBV-DNA was detected by classical dot-blot hybridization in only 24/58 (41%) samples that were positive by the simplified polymerase chain reaction method. Although extremely high sensitivity is not achieved, microwave irradiation of serum simplifies considerably the detection of small amounts of HBV-DNA and makes polymerase chain reaction suitable for monitoring patients in whom weak hepatitis B virus replication is associated with ongoing liver disease.

The emergence of psychosis during antiviral therapy for hepatitis C is a rare side effect poorly understood in terms of etiopathogenesis, clinical features and prognosis. Erotomania is a rare psychotic syndrome characterized by the presence of a delusion: the patient (usually a female) is loved by a specific man. We present a patient who began a clinical picture of erotomania that involved his doctor a few days after treatment of interferon and ribavirin was started. He stalked his doctor, forcing the police and the court to intervene. Nevertheless, once antipsychotic treatment was established, symptoms remitted, and the patient continued antiviral treatment successfully.