[Clinical features of systemic scleroderma with lesions in respiratory organs]

This retrospective study included 64 patients divided into 2 groups. Group 1 was comprised of 34 patients with systemic scleroderma and signs of interstitial lung lesions (X-ray diagnostics), the control group included 30 patients with scleroderma alone. They were examined by general clinical, biochemical and immunological methods, ECG, Echo-CG, capillaroscopy, standard chest X-ray, spirometry, ultrasound studies of internal organs, oesophageal, gastric and duodenal endoscopy. It was shown that systemic scleroderma with signs of interstitial lung lesions is more frequently accompanied by clinical (cough, dyspnea, bilateral inspirational crepitation) and functional (reduced lung vital capacity) pulmonary disorders. Also, these patients have "pursed mouth" appearance, their skeletal muscles and blood circulatory system are involved in the pathological process which accounts for arterial hypertension and mitral valve sclerosis (Echo-CG), reduced hemoglobin level hypergammaglobilinemia, IgA variations, and leukocyturia.

[Choice of antireflux procedure in surgery of gastroesophageal reflux disease]

The article is devoted to the choice of antireflux procedure in surgery of gastroesophageal reflux disease. The mechanisms of the most popular antireflux operations are described. The criteria for selecting options of reconstructions gastroesophageal junction are presented in the article. The theoretical propositions are supported by the results of clinical observations.

Clinic of Gastroenterohepatology--overview of activities

CThe Clinic of Gastroenterohepatology is a part of the Medical Faculty Skopje and University "St. Cyril and Methodius University, Skopje". It is organized as an educational, scientific and medical care institution. CThere are four diagnostic departments: an out-patients department, endoscopic department, ultrasound department and X-ray department. During Over the last several decades, the Clinic of Gastroenterohepatlogy Clinic has been intensively developed, primarily because of introducing the most recent and modern knowledge in gastroenterology, continuous medical education of the personneal as well education of the doctors and other medical personal from the other medical centrers in Macedonia and neighbouring countries. The hospital part of the Clinic is organized in three divisions, including an intensive care unit. In the department of Ultrasound are performed The most modern diagnostic and therapeutic procedures are performed in the Ultrasound department for: different various liver diseases, benign and malignant liver diseases, bilirye ducts obstructions, pancreas diseases, spleen diseases, and various abdominal and kidney diseases.

Performances of Elasto-FibroTest(®), a combination between FibroTest(®) and liver stiffness measurements for assessing the stage of liver fibrosis in patients with chronic hepatitis C

BACKGROUND

FibroTest(®) (FT), and liver stiffness measurement (LSM) are the most validated techniques for the non-invasive assessment of fibrosis in patients with chronic hepatitis C (CHC). The combination between FibroTest(®) and LSM has never been assessed using methods assuming that biopsy is not a perfect gold standard.

AIM

The aim was to assess the performance of a new test the Elasto-FibroTest(®) (EFT) combining FibroTest(®) and LSM.

METHODS

An integrated data base of 1289 patients with biopsy and 604 healthy volunteers was analyzed. EFT took into account the applicability of both tests, included two algorithms taking one for the diagnosis of advanced fibrosis (EFT-F2) and one for the diagnosis of cirrhosis (EFT-F4). Performances of EFTs were assessed by three methods: area under the ROC curve (AUROC), "Obuchowski method" (OBU) and 1 TAGS the "Latent class with random factor".

RESULTS

For the diagnosis of advanced fibrosis EFT-F2 performances (specificity=0.99 and sensitivity=0.83) were not greater than the performances of FibroTest(®) alone (specificity=0.93 and sensitivity=0.99). For the diagnosis of cirrhosis, EFT-F4 performances were greater than those of FibroTest(®) alone, particularly for the sensitivity (0.88 vs. 0.74); when compared with LSM, EFT-F4 performances (specificity=0.99 and sensitivity=0.99) were also greater than those of LSM alone particularly because of its lower specificity (0.92).

CONCLUSION

For the diagnosis of cirrhosis the Elasto-FibroTest(®) has higher performances than FibroTest(®) or FibroScan(®) alone. No improvement in performance has been observed for the diagnosis of advanced fibrosis vs. FibroTest(®) alone.

Gallbladder and gastric motility in obese newborns, pre-adolescents and adults

BACKGROUND AND AIM

Impaired gallbladder and gastric motility have been associated with obesity in adults. The timing of appearance of this dysfunction, however, is unclear.

METHODS

Lean and obese subjects from three different age groups were studied noninvasively: 50 newborns (1-12 months old, six obese), 18 pre-adolescents (7-8 years old, seven obese), and 99 adults (22-80 years old, 32 obese) classified according to standard normal tables and body mass index. Changes of fasting/postprandial gallbladder and gastric motility were assessed simultaneously by functional ultrasonography in response to milk (newborns and pre-adolescents) and to a liquid test meal (adults).

RESULTS

In newborns, fasting and postprandial gallbladder volumes and gastric emptying were similar between obese and lean subjects. In pre-adolescents, obese subjects had a larger fasting gallbladder volume, with slower postprandial gastric emptying than lean subjects. In obese adults, the most evident dysfunction emerged, with larger fasting and postprandial residual gallbladder volume, and slower postprandial gastric emptying than lean subjects.

CONCLUSIONS

Obese subjects display abnormal gallbladder and gastric motility patterns, which first appear in pre-adolescents and deteriorate in adults. Such abnormalities are absent in obese newborns. Functional ultrasonography can detect altered cholecysto-gastric motility at the earliest stage. Our findings suggest an age-related decline of motility, probably secondary to excessive fat and insulin-resistance.

[Gastrointestinal stromal tumors: clinical features and diagnosis]

Gastrointestinal stromal tumors (GIST) are rare, usually sporadic, and mainly located in the stomach or small bowel. Gastrointestinal bleeding is the main presenting symptom. GIST are discovered incidentally in 20% of cases. Endoscopy, and endosonography when possible, are the diagnostic procedures of choice for small GIST, while CT is used for larger tumors. Pathologic diagnosis can be obtained by fine-needle aspiration, but its indications must be discussed on an individual basis.

Prediction tools for unfavourable outcomes in Clostridium difficile infection: a systematic review

CONTEXT

Identifying patients at risk for adverse outcomes of Clostridium difficile infection (CDI), including recurrence and death, will become increasingly important as novel therapies emerge, which are more effective than traditional approaches but very expensive. Clinical prediction rules (CPRs) can improve the accuracy of medical decision-making. Several CPRs have been developed for CDI, but none has gained a widespread acceptance.

METHODS

We systematically reviewed studies describing the derivation or validation of CPRs for unfavourable outcomes of CDI, in medical databases (Medline, Embase, PubMed, Web of Science and Cochrane) and abstracts of conferences.

RESULTS

Of 2945 titles and abstracts screened, 13 studies on the derivation of a CPR were identified: two on recurrences, five on complications (including mortality), five on mortality alone and one on response to treatment. Two studies on the validation of different severity indices were also retrieved. Most CPRs were developed as secondary analyses using cohorts assembled for other purposes. CPRs presented several methodological limitations that could explain their limited use in clinical practice. Except for leukocytosis, albumin and age, there was much heterogeneity in the variables used, and most studies were limited by small sample sizes. Eight models used a retrospective design. Only four studies reported the incidence of the outcome of interest, even if this is essential to evaluate the potential usefulness of a model in other populations. Only five studies performed multivariate analyses to adjust for confounders.

CONCLUSIONS

The lack of weighing variables, of validation, calibration and measures of reproducibility, the weak validities and performances when assessed, and the absence of sensitivity analyses, all led to suboptimal quality and debatable utility of those CPRs. Evidence-based tools developed through appropriate prospective cohorts would be more valuable for clinicians than empirically-developed CPRs.

[Maastricht consensus-4 (2011). Main provisions and comments]

The author reviews the main articles and statements of the newly adopted Maastricht Consensus-4 (2011) on diagnostics and treatment of gastroduodenal diseases associated with H. pylori infection. Each statement is commented taking account of the author's experience and results of Russian and foreign researchers obtained by methods and techniques of evidence-based medicine. Corrected recommendations for diagnostics, therapeutic indications, and strategy of management of H. pylori-dependent diseases are proposed.

[Algorithm of emergency diagnostics of acute bleedings caused by disturbed hemostasis in surgical practice]

On the basis of clinical experience the author substantiates the algorithm of clinico-laboratory emergency diagnostics and differential diagnostics of acute bleedings caused by disturbances of the primary and secondary hemostasis.

Gallbladder motility disorders estimated by non-invasive methods

BACKGROUND/AIMS

The aim is to compare the radionuclide (DC) and ultrasonographic (US) method in the assessment of gallbladder (GB) motility.

METHODOLOGY

The study was performed in 15 controls (C), 10 patients with acute cholecystitis (AC), 20 patients with chronic acalculous cholecystitis (CAC), 26 patients with chronic cholecystitis with calculosis (CCC) as well as in 15 patients with GB dyskinesia (D). GB emptying period (EP), ejection fraction (EF) and ejection rate (ER) were estimated with dynamic cholescintigraphy (DC) and US.

RESULTS

The DC and US finding in the patients with AC was typical in all the patients, i.e. GB was not visualized at all on DC, while on US, stone was visible in the cystic duct. There were significant differences (p<0.05) between the EF and ER values obtained between C and the three groups of patients CAC, CCC and D, using both methods. However, there were no significant differences in EF, EP and ER values among CAC, CCC and D (p>0.05). There was also high correlation between the results obtained with both methods in all the groups of patients studied.

CONCLUSIONS

The results obtained by both methods are valuable for the assessment of GB motility. Although there are no significant differences and there is a high correlation between the values, radionuclide method is more precise, because it can register motility continuously.

[Traumatic diaphragmatic hernia]

Historical and statistical data on traumatic diaphragmatic hernias are presented. It was shown that frequency of occurrence of the pathology in question was dependent on principal causes of its development, anatomic features of diaphragmatic hernias and mechanisms of damage of the diaphragm. In the article the author notes that the worsening of criminogenic situation, increased number of road and traffic accidents were principal causes of the development of diaphragmatic hernias. Special place in the review is given to strangulated diaphragmatic hernias. The basic diagnostic methods for this pathology are radiological investigation, computed tomography and ultrasonic scanning. In addition, the methods of treatment, prognosis of the development of diaphragmatic hernias, complications included, are presented.

[Fulminant acute pancreatitis. Are there objective criteria of the disease?]

A retrospective analysis has been made of the results of the diagnosis and treatment of 71 patients having severe pancreatitis. As a result, factors were revealed which restrict the possibilities of conservative treatment associated with pessimistic prognosis of the disease. Among them there are pancretitis-specific organic abnormalities (pulmonary, cardio-vascular, renal dysfunctions), diffused pancreonecrosis and infection of destructive zones. All the parameters in question are included in the proposed model of prognosis of the fulminant course of pancreatitis having high diagnostic accuracy up to 88.3%.

[Hepatorenal syndrome]

BACKGROUND

Hepatorenal syndrome (HRS) is a particular form of functional renal failure which may develop in patients with liver cirrhosis. Recent advances in the understanding of the biology of vasoactive mediators and the physiology of microcirculation have allowed to better anticipate its pathophysiological mechanisms.

AIM

To review new advances in the knowledge of epidemiology, diagnosis criteria, pathophysiological mechanisms and treatment of HRS.

METHODS

Review of literature using medical data bases (Medline) with the following key words: hepatorenal syndrome, pathophysiology, medical treatment, MARS, liver transplantation.

RESULTS

During the course of cirrhosis, portal hypertension leads to splanchnic and systemic vasodilation, responsible for a reduction of effective arteriel blood volume. As a result, a state of intense renal vasoconstriction develops, leading to renal failure in the absence of any organic renal disease. At this stage, liver transplantation is the only definitive therapy able to reverse renal dysfunction. Pharmacologic and radiologic therapy is aimed at improving renal function to enable patients to survive until transplantation is possible. These therapies are based on vasoconstrictor drugs associated with intravenous albumin infusion and transjugular intrahepatic portosystemic shunt (TIPS). They improve circulatory function, normalize serum creatinine and may improve survival.

CONCLUSION

Simple measures have been shown to reduce the risk of HRS in cirrhotic patients including the plasma volume expansion with albumin in patients with spontaneous bacterial peritonitis and optimal fluid management in patients undergoing large volume paracentesis.

[Is there a place for the Glasgow-Blatchford score in the management of upper gastrointestinal bleeding?]

BACKGROUND

Upper gastrointestinal bleeding is a frequent cause for emergency hospital admission. Most severity scores include in their computation the endoscopic findings. The Glasgow-Blatchford score is a validated score that is easy to calculate based on simple clinical and biological variables that can identify patients with a low or a high risk of needing a therapeutic (interventional endoscopy, surgery and/ or transfusions).

AIM

To validate retrospectively the Glasgow-Blatchford Score (GBS).

METHODS

The study examined all patients admitted in both the general surgery department as of Anesthesiology of the Regional Hospital of Sidi Bouzid. There were 50 patients, which the mean age was 58 years and divided into 35 men and 15 women. In all these patients, we calculated the GBS. Series were divided into 2 groups, 26 cases received only medical treatment and 24 cases required transfusion and / or surgery. Univariate analysis was performed for comparison of these two groups then the ROC curve was used to identify the 'Cut off point' of GBS. Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) with confidence interval 95% were calculated.

RESULTS

The SGB was significantly different between the two groups (p <0.0001). Using the ROC curve, it was determined that for the threshold of GBS ³ 7, Se = 96% (88-100%), Sp = 69% (51-87%), PPV = 74% (59 -90%) and NPV = 95% (85-100%). This threshold is interesting as to its VPN. Indeed, if GBS <7, we must opt for medical treatment to the risk of being wrong in only 5% of cases.

CONCLUSION

The Glasgow-Blatchford score is based on simple clinical and laboratory variables. It can recognize in the emergency department the cases that require medical treatment and those whose support could need blood transfusions and / or surgical treatment.

[Exploration and approach to artificial airway dysphagia]

Airway isolation by endotracheal intubation or tracheostomy impedes or even interrupts speech and swallowing. Pharyngeal and laryngeal impairment frequently occurs after extubation or de-cannulation, common consequences being dysphonia, dysphagia and the aspiration of oral secretions, food, or fluids. Aspiration often leads to pneumonia and eventually death. Although the literature reports a high frequency of dysphagia following intubation and tracheostomy, the data vary considerably, and the true incidence of oropharyngeal dysphagia following artificial airway isolation remains to be established. We conducted a systematic review of the available evidence, in order to assess oropharyngeal dysphagia physiology, diagnosis and treatment.

What is necessary to diagnose constipation?

Constipation is a common ailment with multiple symptoms and diverse etiology. Understanding the pathophysiology is important to guide optimal management. During the past few years, there have been remarkable developments in the diagnosis of constipation and defecation disorders. Several innovative manometric, neurophysiologic, and radiologic techniques have been discovered, which have improved the accuracy of identifying the neuromuscular mechanisms of chronic constipation. These include use of digital rectal examination, Bristol stool scale, colonic scintigraphy, wireless motility capsule for assessment of colonic and whole gut transit, high resolution anorectal manometry, and colonic manometry. These tests provide a better definition of the underlying mechanism(s), which in turn can lead to improved management of this condition. In this review, we summarize the recent advances in diagnostic testing with a particular emphasis on when and why to test, and discuss the utility of diagnostic tests for chronic constipation.

Observational, nonintervention, multicenter study for validation of the Bowel Function Index for constipation in European countries

OBJECTIVE

Constipation is a common adverse event of treatment with opioids for chronic non-malignant pain and may result in a considerable reduction in health-related quality of life. The aim of this study was to assess the psychometric properties of the Bowel Function Index (BFI) in european patients suffering from constipation secondary to opioid analgesic treatment for chronic, non-malignant pain.

METHODS

This was a multinational study conducted at 15 clinical sites in the Czech Republic, Germany, Italy, and the United Kingdom. Patients suffering from constipation secondary to opioid analgesic treatment for chronic, non-malignant pain were recruited to complete a series of questionnaires including a socio-demographic form, the BFI, the Patient Assessment of Constipation - Symptoms (PAC-SYM), a global frequency item, and a clinical form.

RESULTS

A total of 131 patients were included in this study. Inter-item correlations of the BFI were statistically significant in the moderate to large range and the analysis indicated a strong degree of internal consistency (Cronbach's alpha = 0.86). All correlations between the BFI and the global item were statistically significant in the moderate to high range (r = 0.59 to 0.69; p < 0.0001). Correlations between the BFI and the PAC-SYM were moderate and statistically significant (p < 0.01 to 0.0001).

CONCLUSIONS

Although this study was limited by the relatively small sample size, it is a part of an extensive validation program. This study suggests that the BFI is a reliable and valid measure of constipation-related symptomatology in chronic pain patients. This measure may be a valuable indicator of patients' experience of symptoms of opioid treatment of chronic pain in future trials.

Biliary brush cytology in the assessment of biliary strictures at a tertiary center in Iran

BACKGROUND

Confirmation of cholangiocarcinoma and other malignant bile duct stenosis is challenging. The aim of the current study was to assess the accuracy of brush cytology for diagnosis of malignant biliary strictures.

METHODS

105 patients with hepatic biliary strictures undergoing ERCP were included in this study. Prospectively collected data included symptoms, results of biochemical testing and imaging procedures, as well as details of ERCP. Exclusion criteria were: 1) strictures that would not permit passage of guidewire and brush accession; and 2) post-operative strictures. Brushings of the bile duct strictures were performed. All patients were followed for at least 6 months. The final diagnosis was confirmed following surgery, histopathological diagnosis of the lesion, radiological infiltration of adjacent organs or metastases, or after at least a 6-month follow-up.

RESULTS

88 brush samples from 88 patients were of appropriate quality. The overall diagnostic sensitivity and specificity for malignant nature of biliary strictures were 40.7% and 100%, respectively. The sensitivity was 66.6 % for ampullary carcinomas, 36.3% for pancreatic cancer and 32.5% for cholangiocarcinomas.

CONCLUSIONS

Despite the low sensitivity, due to the relative ease and safety, brush cytology should remain the first choice for diagnosis of causes of biliary strictures.

Determination of the frequency of dyssynergic defecation and patient characteristics in patients with functional constipation

BACKGROUND/AIMS

Dyssynergic defecation, a subgroup of functional constipation, is a relatively new definition, diagnostic criteria of which have recently been described. Distribution of subgroups of functional constipation in our population is scarcely known. We aimed to evaluate the demographic characteristics and defecation features of patients as we determined the frequency of dyssynergic defecation in patients with functional constipation in our community.

METHODS

Eighty-two patients, 52 women and 30 men, with functional constipation were included in the study by using a questionnaire after secondary causes were excluded. Colonic transit time and balloon expulsion tests were performed to determine sub-groups of functional constipation. Colonoscopy and/or sigmoidoscopy in all patients and double contrast colonography in some patients were obtained at the beginning of the study to exclude anatomic and organic causes and patients with constipation predominant irritable bowel syndrome were also excluded from the study.

RESULTS

The results of the study revealed that functional constipation in our community occurs more frequently in women and at relatively older (middle to old) age. Patients with normal transit constipation pattern are the largest portion (52.4%) of patients with functional constipation, whereas dyssynergic defecation is the second most frequent (25.6%) reason among this population.

CONCLUSION

The frequency of dyssynergic constipation is lower in our population compared to western communities, but the symptoms are similar. We believe that the questionnaire we used is helpful in revealing defecation characteristics and when combined with balloon expulsion test and colonic transit time measurements it can be a valuable tool in the diagnosis of dyssynergic defecation.