Comparison between preoperative quantitative assessment of bowel wall vascularization by contrast-enhanced ultrasound and operative macroscopic findings and results of histopathological scoring in Crohn's disease

PURPOSE

Patients with Crohn's disease (CD) often undergo several radiological imaging studies, which - with the exception of MRI and US - subject patients to ionizing radiation. Thus, efforts have been made to identify the inflammation activity using ultrasound techniques. The aim of our study was to describe the perfusion pattern of the inflamed bowel wall in CD using contrast-enhanced ultrasound (CEUS) and specific quantification software for perfusion assessment. Moreover, we compared these findings with the operative macroscopic findings as well as with the transparietal histopathological findings of surgical specimens applying an advanced histopathological scoring system.

MATERIALS AND METHODS

We prospectively performed CEUS in 20 consecutive patients with proven CD and planned bowel surgery due to CD within the next 15 days. We then applied the quantification software Qontrast to obtain contrast-enhanced sonographic perfusion maps. The surgeon defined the clinical behavior of CD according to the Vienna classification. The resected segments were then assessed by a pathologist using an advanced scoring system. We compared the results of CEUS, macroscopic findings and histopathological scoring.

RESULTS

We found a strong negative correlation (r = - 0.677, p < 0.01) between the histopathological score and the time-to-peak (TTP). Moreover, we detected a strong correlation between TTP and single parameters of the histopathological scoring system.

CONCLUSION

Ultrasound as a widely available radiation-free imaging method would be preferable for assessing inflammatory activity of CD, particularly since the ultrasound findings correlate significantly with a histopathological scoring system.

The influence of erythrocyte aggregation on induced platelet aggregation

Red blood cells (RBCs) affect platelet aggregation in flowing blood (primary hemostasis). We tested the hypothesis that RBC aggregation could influence platelet aggregation. RBC aggregation was altered in vitro by: (i) changing plasma aggregatory properties with 3.7 g% dextran 40 (D40), 3.0 g% dextran 70 (D70) or 1.55 g% dextran 500 (D500); (ii) changing RBC aggregatory properties by incubating RBCs in 50 mU/ml neuraminidase for 60 min (reduction of the surface sialic acid content, thus reducing electrostatic repulsion) and subsequent RBC resuspension in platelet rich plasma (PRP) containing 1 g% dextran 70. RBC aggregation was assessed with the sedimentation rate (ESR). Platelet aggregation was measured: (i) in flowing whole blood with a platelet function analyzer PFA-100(R), which simulates in vivo conditions with RBCs flowing in the center and platelets along the wall, where they adhere to collagen and aggregate; and (ii) in a Chrono-log 700 Aggregometer, which measures changes of impedance by platelet aggregation in whole blood or changes in light transmission in PRP. We found that RBC aggregation increased with increasing molecular weight of dextran (ESR: 4 +/- 3 mm/h, 34 +/- 14 mm/h and 89 +/- 23 mm/hfor D40, D70 and D500, respectively, p < 0.0001) and with neuraminidase-treated RBCs (76 +/- 27 mm/h vs 27 +/- 8 mm/h, respectively, p < 0.0001). Platelet aggregation measured in whole blood under flow conditions (PFA-100) and without flow (Chronolog Aggregometer) was not affected by RBC aggregation. Our data suggest that RBC aggregation does not affect platelet aggregation in vitro and plays no role in primary hemostasis.

Control of cancer-associated inflammation and survival: Results from a prospective randomized phase II trial in gastric cancer

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Background: An angiostatic approach was used to assess the impact of anti-inflammatory therapy in combination with metronomic low-dose chemotherapy. Methods: A randomized multi-institutional phase II trial was designed to select metronomic chemotherapy (arm A: capecitabine 1 g orally twice daily for 14 days with one week break until tumor progression) or combined anti-inflammatory/angiostatic treatment (arm B: capecitabine as mentioned above plus etoricoxib 60 mg orally, day 1+, and pioglitazone 60 mg orally, day 1+) for further evaluation. Patients with refractory or progressive disease following any first-line therapy except capecitabine or frail were eligible. According to the one stage design, a sample size of 64 patients was calculated for the primary objective, improvement of response rate. Results: As similar response rates were observed (arm A/B 15/14%) after the accrual of 42 patients, the study was closed (n=20 (A), n=22 (B); median age 69 years (range 46 to 86ys); frail A/B n=9/11). Median progression- free survival for arm A/B was 3.0/2.9 months (P=0.878), and overall survival 5.0/6.1 months (P=0.778). In both treatment arms a significant decline of serum C-reactive protein (CRP) levels was observed within the first 4 to 6 weeks on treatment, A/B P= 0.01/0.04, respectively. CRP response > 50% from baseline was associated with a significantly improved overall survival in arm A/B (3.1 versus 11.0 months, P= 0.023/ 3.3 versus 7.1 months, P= 0.078) indicating an impact of inflammation-control on survival. WHO grade 3 (no grade 4) toxicities were reported in arm A/B in 20% and 23%, respectively, mostly due to hand-foot-syndrome. Conclusions: Metronomic low- dose chemotherapy in gastric cancer may induce anti-inflammatory response, but the chosen additional anti-inflammatory approach neither has impact on tumor-associated inflammation nor on response or survival rate. In a historical comparison, CRP-responder have similar outcome as patients treated with combination chemotherapy in first-line.

No significant financial relationships to disclose.

Self-expanding Polyflex plastic stents in esophageal disease: various indications, complications, and outcomes

BACKGROUND

Esophageal stenting has become an important technique in the treatment of different clinical problems such as malignant or benign stenosis, anastomotic leaks after surgery, or fistulas. In this study we present our experience with the self-expanding Polyflex plastic stent in various indications, arising complications, and patient's outcomes.

METHODS

Over a three-year period, 35 patients underwent self-expanding Polyflex plastic stent placement for esophageal stenosis (n = 23) with 22 malignant, and for perforations, fistulas, or anastomotic leaks after surgery (n = 12). The short-term efficacy and long-term outcomes were analyzed.

RESULTS

In patients with stenosis, implantation was performed without any complications in 91% (21/23). In one patient perforation occurred while passing the stenosis; in another patient the stent dislocated during the insertion procedure. Dysphagia score improved from 3.0 to 1.0 after stenting. In all patients with perforations, fistulas, or anastomotic leaks (n = 12), stents were placed successfully without any complication. Complete sealing of the mucosal defect was proven by radiography in 92% (n = 11) and healing was seen in 42% (n = 5). If indicated, stent removal was performed without any complications. Stent migration (n = 13; 37%) was the most common long-term complication.

CONCLUSIONS

The placement of self-expanding Polyflex plastic stents is a highly sufficient and cost-effective treatment for malignant and benign esophageal disorders. Because the long-term results were highly favorable, self-expanding plastic stent placement could be used as the initial treatment for various conditions.

[The clinical significance of cosmic radiation in aviation]

The possible adverse health effects of cosmic radiation remains an important topic in the consultation of aviators and frequent flyers. A good number of articles, dealing with this questions have been published recently but produced controversial results.

METHODS

We performed a Medline database search and identified 20 relevant articles that were published between 1990 and 2003. There were one retro-/prospective, 13 retrospective, 3 prospective cohort studies and 3 metaanalysis reviewed. Sixteen studies were set in the civil aviation environment, two studies in the military aviation environment and two studies were set in both environments.

RESULTS

Seven out of nine studies found an identical or decreased over-all-risk for aviators to develop cancer of any kind compared to the general population. In re- gards to skin cancer, seven out of eight studies found an increased risk for aviators to develop malignant melanoma, basalioma or other kinds of skin cancer. Three studies found an increased risk for the development of prostate cancer and two studies were able to demonstrate a higher risk for the appearance of leukaemia.

CONCLUSIONS

Although our review found some studies, that identified higher risks for pilots to develop cancer of the skin, prostate cancer or leukaemia, there is not enough scientific evidence to support the hypothesis, that cosmic radiation is the cause for these findings. It shows to be important to include other factors in the interpretation of the results, since some of the findings may be well explained by life-style factors of the aviation community.

Methane oxidation in a landfill cover with capillary barrier

The methane oxidation potential of a landfill cover with capillary barrier was investigated in an experimental plant (4.8 m x 0.8 m x 2.1m). The cover soil consisted of two layers, a mixture of compost plus sand (0.3 m) over a layer of loamy sand (0.9 m). Four different climatic conditions (summer, winter, spring and fall) were simulated. In and outgoing fluxes were measured. Gas composition, temperature, humidity, matrix potential and gas pressure were monitored in two profiles. CH4 oxidation rate within the investigated top cover ranged from 98% to 57%. The minimum was observed for a short time after irrigation. Temperature distribution, gas concentration profiles and lab-scaled batch experiments indicate that before irrigation the highest oxidising activity took place in a depth of about 30 cm. After irrigation the oxidising horizon seemed to migrate upwards since methanotrophic bacteria develop better there due to an adequate supply with oxygen. It can be assumed that the absence of oxygen is one of the most important limiting factors for the CH4 oxidation process. Abrupt cross-overs between horizons of different soil material may lead to zones of increased water saturation and decreased soil respiration.