Circulating biomarkers in neuroendocrine tumors of the enteropancreatic tract: application to diagnosis, monitoring disease, and as prognostic indicators

Neuroendocrine tumors (NETs) are difficult to diagnose. Their symptoms may be vague or intermittent, and are frequently associated with much more common diseases; many of the tumors may be asymptomatic. Therefore, diagnosis can be delayed for some years. Because most NETs are secretory, the measurement of circulating biomarkers is helpful not only for diagnosis but also for assessing tumor response to treatment, monitoring disease progression, and use as prognostic indicators.

[Evaluation of surgical outcomes using imaging study for patients with slow transit constipation complicated with outlet obstruction]

OBJECTIVE

To explore the clinical significance of multiple radiography of the pelvis in the evaluation of surgical outcomes for patients with slow transit constipation complicated with outlet obstruction.

METHODS

Patients with slow transit constipation complicated with outlet obstruction were diagnosed by multiple radiography of the pelvis after screening using colon transit study. Surgery was performed according to the cause of the obstruction. Anorectal angle and the locations of perineum, pelvic peritoneum, and bladder were assessed by multiple radiography of the pelvis one month after surgery. The changes in locations of pelvic organs were assessed and the imaging appearance after the release of obstruction was observed.

RESULTS

A total of 48 patients were included. Rectocele repair, partial mucosectomy with rectopexy, and hysteropexy were performed. All the patients were followed up with a mean length of 19(6-58) months. Excluding 2 patients who had no symptomatic improvement, the mean bowel movements was 1.9 times per day in the remaining 46 patients(95.8%). Preoperative anorectal angle at the squeezing phase was(128.09±13.82) degree and the difference between squeezing and resting phase was (11.14±12.58) degree, while the postoperative angle was (180.26±9.98) degree and the difference(20.01±13.11) degree(P<0.05). Preoperative location of the perineum at the squeezing phase was(-2.05±0.83) cm and the difference was(2.23±0.78) cm, while postoperative location was (-0.50±1.13) cm and the difference was (2.18±1.04) cm(P<0.05). Preoperative location of the pelvic peritoneum at the squeezing phase was(4.91±1.32) cm and the difference was (1.32±0.89) cm, while postoperative location was (2.62±2.53) cm and the difference was (3.28±0.68) cm (P<0.05). Preoperative bladder location at the squeezing phase in patients with urological symptoms was (3.92±2.51) cm and the difference was(1.39±1.27) cm, while postoperative location was (2.15±1.55) cm and the difference was (1.98±1.54) cm(P<0.05).

CONCLUSION

Multiple imaging of the pelvis provides objective evidence in the evaluation of surgical outcomes for patients with chronic slow transit constipation complicated with outlet obstruction.

A meal test improves the specificity of chromogranin A as a marker of neuroendocrine neoplasia

Chromogranin A (CgA) is a neuroendocrine tumor (NET) marker. Modest CgA elevation is found in subjects with enterochromaffin-like (ECL) cell hyperplasia due to hypergastrinemia. Somatostatin analogs reduce CgA levels in patients with NET. Meals may affect serum CgA levels. The aims of the study were to investigate meal-induced CgA release and the short-term effect of octreotide on serum CgA levels. Four groups were studied: group A, seven patients with ECL cell hyperplasia secondary to use of proton pump inhibitors (PPIs); group B, six patients with gastric carcinoid type 1/ECL hyperplasia due to chronic atrophic gastritis (CAG); group C, six patients with nongastric NETs; group D, seven controls. The subjects were studied on three separate days with the use of three exposures: a test meal, pentagastrin subcutaneously (not group C), and octreotide intravenously. Serum CgA and gastrin were analyzed. A test meal induced a significant CgA increase in long-term PPI users and in healthy controls. The meal did not affect CgA levels in patients with gastric carcinoid type 1 or patients with NETs. The test meal increased gastrin levels in all groups except in those with CAG. Pentagastrin increased CgA levels in all groups tested except in those with CAG, while octreotide, reduced CgA and gastrin levels in all groups. Serum CgA should be determined in fasting individuals. A test meal may distinguish between increased CgA levels in PPI users from nongastric NET patients. Concomitant gastrin determination may help to discriminate between nongastric NETs and CAG. Intravenous octreotide rapidly reduces serum CgA.

Diagnostic testing for celiac disease among patients with abdominal symptoms: a systematic review

CONTEXT

The symptoms and consequences of celiac disease usually resolve with a lifelong gluten-free diet. However, clinical presentation is variable and most patients presenting with abdominal symptoms in primary care will not have celiac disease and unnecessary diagnostic testing should be avoided.

OBJECTIVE

To summarize evidence on the performance of diagnostic tests for identifying celiac disease in adults presenting with abdominal symptoms in primary care or similar settings.

DATA SOURCES

A literature search via MEDLINE (beginning in January 1966) and EMBASE (beginning in January 1947) through December 2009 and a manual search of references for additional relevant studies.

STUDY SELECTION

Diagnostic studies were selected if they had a cohort or nested case-control design, enrolled adults presenting with nonacute abdominal symptoms, the prevalence of celiac disease was 15% or less, and the tests used included gastrointestinal symptoms or serum antibody tests.

DATA EXTRACTION

Quality assessment using the Quality Assessment of Diagnostic Accuracy Studies tool and data extraction were performed by 2 reviewers independently. Sensitivities and specificities were calculated for each study and pooled estimates were computed using bivariate analysis if there was clinical and statistical homogeneity.

DATA SYNTHESIS

Sixteen studies were included in the review (N = 6085 patients). The performance of abdominal symptoms varied widely. The sensitivity of diarrhea, for example, ranged from 0.27 to 0.86 and specificity from 0.21 to 0.86. Pooled estimates for IgA antiendomysial antibodies (8 studies) were 0.90 (95% confidence interval [CI], 0.80-0.95) for sensitivity and 0.99 (95% CI, 0.98-1.00) for specificity (positive likelihood ratio [LR] of 171 and negative LR of 0.11). Pooled estimates for IgA antitissue transglutaminase antibodies (7 studies) were 0.89 (95% CI, 0.82-0.94) and 0.98 (95% CI, 0.95-0.99), respectively (positive LR of 37.7 and negative LR of 0.11). The IgA and IgG antigliadin antibodies showed variable results, especially for sensitivity (range, 0.46-0.87 and range, 0.25-0.93, respectively). One recent study using diamidated gliadin peptides showed good specificity (> or = 0.94), but evidence is limited in this target population.

CONCLUSION

Among adult patients presenting with abdominal symptoms in primary care or other unselected populations, IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies have high sensitivity and specificity for diagnosing celiac disease.

Faecal calprotectin concentrations in children with functional gastrointestinal disorders diagnosed according to the Pediatric Rome III criteria

OBJECTIVE

To determine if faecal calprotectin concentrations vary with different entities of functional gastrointestinal disorders (FGID) in children.

METHODS

Children (4-15 years) who were consecutively referred by general practitioners to four general paediatric outpatient clinics for the evaluation of recurrent abdominal pain were assessed according to a research protocol which included clinical examination, a minimum set of blood, urine and stool tests, and clinical reassessment after 6-9 months. The diagnoses of FGID were based on the parent version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III.

RESULTS

Of the 152 patients included, 142 children were diagnosed with FGID. Of these, 126 (89%) provided a stool specimen for quantification of calprotectin. The median calprotectin concentrations were at or lower than 16 mg/kg which was at the lower detection limit and there were no differences between the FGID subgroups. Nine children (7%) had slightly raised values.

CONCLUSION

The faecal calprotectin concentration is within normal limits in FGID and does not vary with different FGID entities suggesting that bowel inflammation is not a significant part of the pathogenesis in FGID.

Tzanakis score vs. Alvarado score in acute appendicitis

INTRODUCTION

Acute appendicitis is a common surgical emergency. Accurate diagnosis and timely intervention reduces mortality and morbidity. This study compared the efficacy of Tzanakis and Alvarado score in diagnosis of acute appendicitis.

METHODS

A prospective, non randomized study was conducted in 100 consecutive patients who had undergone emergency appendectomy from May 2008 to October 2008. Tzanakis and Alvarado scores were obtained at the time of admission. Final diagnosis of acute appendicitis was based on histological findings.

RESULTS

The sensitivity, specificity and overall diagnostic accuracy of Tzanakis score was 91.48% and 66.66% and 90% respectively. The sensitivity, specificity and overall diagnostic accuracy of Alvarado score was 81.91% and 66.66% and 81% respectively. Negative appendectomy rate was 6%.

CONCLUSIONS

Tzanakis score is an effective modality to establish the accurate diagnosis of acute appendicitis.

Role of the primary care provider in the diagnosis and management of heartburn

BACKGROUND

Heartburn affects an estimated 42% of the US population. Often, patients are able to recognize symptoms and self-treat heartburn; however, patients with more persistent and/or troublesome symptoms should be evaluated by a physician or other healthcare provider.

SCOPE

This review focuses on the role of the primary care provider in the diagnosis and treatment of heartburn.

METHODS

A search was conducted on PubMed (to November 2009) and articles relevant to the management of heartburn by a primary care provider topic were selected.

FINDINGS

Diagnostic tools, such as endoscopy, and ambulatory pH monitoring, are recommended for advanced assessment of patients with frequent heartburn to avert misdiagnosis and to identify complications of reflux disease. Over-the-counter and prescription treatments for frequent heartburn symptoms include antacids, histamine(2)-receptor antagonists (H(2)RAs), antacid/H(2)RA combinations, and proton pump inhibitors (PPIs). Among these, PPIs represent the mainstay of acute and maintenance treatment regimens in reflux disorders and are more effective than H(2)RAs for long-term use due to the development of tolerance to the latter therapy. While once-daily PPI therapy may be sufficient in most patients, a few may require twice-daily PPI therapy to alleviate their symptoms. This review is limited by its relatively narrow focus on articles cited in PubMed.

CONCLUSION

The primary care provider is ideally situated to advise patients on the best treatment option for their condition and to provide follow-up care if required.

Interventional EUS for the diagnosis and treatment of locally advanced pancreatic cancer

Endoscopic ultrasound (EUS) evolved as the diagnostic test of choice evaluating suspected pancreatic tumors. Coupled with fine needle aspiration (FNA), EUS provides high accuracy for the diagnosis and staging of pancreatic cancer. Novel EUS based techniques have emerged as a safe minimally invasive alternative to the surgical or radiological approaches. By allowing better pain control, delivering antitumor therapies or draining obstructed bile ducts, such techniques hold a big promise to improve the quality of life of patients with unresectable pancreatic cancer. In this review, we will discuss the role EUS-FNA plays in the diagnosis, staging and treatment of patients with locally advanced pancreatic cancer.

[Acute abdominal syndrome in blood system diseases]

AIM

To define an optimal diagnostic and therapeutic algorithm when the acute abdominal syndrome occurs in hematological patients.

MATERIALS AND METHODS

The results of 145 emergency surgeries made in 2006-2008 for acute abdominal syndrome were studied in patients with blood system diseases.

RESULTS

Clinical manifestations of acute abdominal syndrome emerge in 1-1.4% of all the patients treated at the Hematology Research Center, Russian Academy of Medical Sciences. There is a need for surgery in 0.5-0.7% of all the patients admitted. In this group of patients, annual postoperative mortality is 12-16%.

CONCLUSION

The routine algorithm for a diagnostic search in hematological patients with acute abdominal syndrome can lead to both hyperdiagnosis and unwarranted surgery, and incorrect choice of expectant policy as well.

[Irritable bowel syndrome: criteria and clinical view]

The syndrome diagnosis 'irritable bowel syndrome' (IBS) is often made on the basis of exclusion, but the question is how many diagnostic tests should be performed in order to establish this diagnosis with a degree of confidence. We present the diagnostic value of various IBS criteria for excluding IBS, based on a systematic review. The potential of the various criteria for distinguishing IBS from organic disease is extremely variable and disappointing. Patients fulfilling IBS criteria have, however, a lower risk of organic disease than patients with abdominal symptoms who do not fulfil the criteria. The same holds true for the diagnostic performance of individual alerting symptoms. These seem to be present frequently in IBS patients in whom there is no underlying organic bowel condition. An organic condition cannot be accurately excluded on the basis of symptom criteria. However, the low prior risk of organic conditions among patients who consult a primary care doctor and who meet IBS criteria argues against exhaustive diagnostic evaluation.

[Results of evaluating the functional state of the gastric mucosa in duodenal peptic ulcer by means of a test gastropanel in workers engaged in the manufacture of nitrogen compounds]

AIM

to study the specific features of working conditions in workers from the chemical plants manufacturing nitrogen compounds by the groups under study and by the time course of changes in the serum levels of gastrin-17 (G-17) and pepsinogen-1 (P-1) in relation to the chemical composition of noxious substances, the length of service, the stage of the disease, and the performed therapy.

SUBJECTS AND METHOD

A test GastroPanel was used to study the serum levels of G-17 and P-1 in 54 patients with duodenal peptic ulcer (DPU) who worked at the chemical plants manufacturing nitrogen compounds (a study group) and in 15 healthy individuals (a control group).

RESULTS

The objective data on the time course of changes in the functional characteristics (G-17 and P-1) of the gastric mucosa (GM) in patients with DPU vary with the chemical composition of noxious substances and the length of service in chemical industry. The basic therapy for PDU contributes to a positive change in the functional parameters reflecting the state of GM.

CONCLUSION

In patients with DPU, the working conditions at the chemical plants manufacturing nitrogen compounds result in changes in the functional parameters reflecting the state of GM

Early diagnosis of neonatal cholestatic jaundice: test at 2 weeks

OBJECTIVE

To review best practices for early recognition and treatment of conditions resulting in neonatal cholestasis, in order to improve long-term outcomes for affected infants.

QUALITY OF EVIDENCE

Studies, review articles, and meta-analyses pertaining to neonatal-onset cholestasis were sought via electronic databases. Reference lists of studies and review articles supplemented the electronic search. Studies were included if they examined the importance of early diagnosis and intervention for cholestatic jaundice of any cause, and mainly comprised Level II and Level III evidence.

MAIN MESSAGE

Review of the relevant literature supports the recommendation that infants with jaundice at 2 weeks of age should be tested for cholestasis by quantifying the direct reacting bilirubin levels in their blood. Subsequent rapid investigation using a diagnostic algorithm enables early diagnosis of the specific cause and facilitates timely intervention for conditions whose outcomes are improved by early treatment.

CONCLUSION

Universal screening for neonatal cholestasis might help with early identification of cases and improve outcomes, although further study is required in the North American setting.

[Study for phagaquosonogram acquisition module based on DSP]

In this paper, a phagaquosonogram acquisition, a module with TMS320C6713 as a core, and USB as communicating pattern is introduced based on VC++6.0. The structure of the module, hardware configuration, software design and the experiment of the real phagaquosonogram signal collection are presented. It is shown that the module can extract human phagaquosonogram signal reliably and availably.

Assessing gastrointestinal symptoms and perception, quality of life, motility, and autonomic neuropathy in clinical studies

Imprecise characterization of complaints of the upper and lower gastrointestinal (GI) tract puts patients at risks of either a delayed diagnosis or misdiagnosis and contributes to an increase in the overall direct and indirect costs of the health system. The current scenario in the case of functional GI diseases originates from at least two conditions: frequency of diseases and bothersome symptoms with an impact on the quality of life (QoL). To make a correct diagnosis is therefore almost mandatory. Once a positive diagnosis of functional involvement of the GI tract is made, the correct diagnosis assessment includes the study of symptom characteristics, entity and perception, detection of abnormal patterns of GI motor-function (gallblader and gastric emptying, oro-cecal and colonic transit, etc.), potential involvement of the autonomic nervous system (sympathetic, parasympathetic), and overall impact of such abnormalities on the QoL and psychological profiles. Results of these tests can be variable, depending on the type and intensity of the illness. In the present review, the state-of-the-art methods for correct assessment of several factors regarding the onset, perpetuation and outcome of functional GI diseases are discussed.

Analysis of new diagnostic methods in suspicious lesions of the oral mucosa

OBJECTIVE

The objective of this study was to analyse publications related to examination techniques that might improve the visualisation of suspicious lesions of the oral mucosa (ViziLite system and VELscope system) or that might facilitate the cytological identification of suspicious lesions (OralCDx).

METHODS

A literature search was performed, using the PubMed database and the key words "brush biopsy", "OralCDx", "ViziLite" and "Velscope", limiting the search to papers in English or Spanish published from 2002 to 2008.

RESULTS

According to the results of studies identified, the ViziLite system has a sensitivity of 100% and specificity ranging from 0-14.2%, the VELscope system has a sensitivity of 98-100% and specificity of 94-100% and the Oral CDx system has a sensitivity of 71.4-100% and specificity of 32-100%.

CONCLUSION

Clinical examination and histopathological confirmation with biopsy remain the gold standard for the detection of oral cancer. More randomised controlled studies are needed to confirm the positive cost-benefit relationship and the true usefulness of these "new diagnostic methods" in oral mucosal pathology.

[Helicobacter pylori 25 years after (1983 -2008): epidemiology, microbiology, pathogenics, diagnostics and treatment]

EPIDEMIOLOGY

People have been infected by this bacteria 58,000 years ago. Prevalence of infection varies in different nation. In developing countries infection is acquired in early childhood. The forms of infection are/fecal-oral, oral-oral an gastro oral. In Perú we found same prevalence in the coast, jungle and sierra and described that water is one of the ways of infection.MICROBIOLOGY: Three strains predominant in Spanish, Asiatic and people from India have been identified. DNA has 1.65 million bases. Different factors of virulence, enzymes and toxins have also been described.

PATHOGENESIS

Inflamatory response; neutrophiles, lymphocytes T and B, plasma cells, macrophages.METHODS OF DIAGNOSIS: Invasive and non invasive procedures.

THERAPY

Different treatment schemes are described: 1st, 2nd, 3rd lines, rescue therapies. Secondary reactions, alternative schemes, recurrence, reinfection and experience in Perú are also described.

Improving noninvasive methods of assessing liver fibrosis in patients with hepatitis C virus/human immunodeficiency virus co-infection

BACKGROUND & AIMS

Liver fibrosis is a significant concern for patients with hepatitis C virus/human immunodeficiency virus co-infection. Fibrosis staging by biopsy is accurate, but costly and invasive. Several fibrosis prediction models using noninvasive biomarkers have been developed but are suboptimal in co-infected patients. We compared results from different staging models and ordinal regression with biopsy data.

METHODS

Data from the Adult Acquired Immune Deficiency Syndrome Clinical Trials Group protocol A5178 were used to evaluate 5 models of fibrosis staging; areas under receiver-operator characteristic curves (AUROC) were assessed. Individual covariates were assessed with univariable regression and then entered into an ordinal logistic regression model from which a stage-wise index was developed.

RESULTS

Data from 173 patients were evaluated; 85% were on antiretroviral therapy, 31.2% had severe fibrosis (F3/F4), and 14% had cirrhosis (F4). Differences in CD4+ cell and platelets counts and international normalized ratio values were observed between those with and without F3/F4. Among existing models, the FIB-4 index ([age x AST])/[platelet count x (ALT)(1/2)]) performed best, with 88% specificity for F4 and greater than 86% negative predictive values for F3/F4, although AUROC values were low (0.56 +/- 0.03 for F3/F4). By using patients' demographic, clinical, and laboratory data, the ordinal regression model outperformed others, with an AUROC of 0.85 (standard error, 0.03) for predicting stage F3/F4 and 0.89 (standard error, 0.05) for stage 3 alone.

CONCLUSIONS

Current noninvasive methods of fibrosis assessment have poor discriminatory capacity in hepatitis C virus/human immunodeficiency virus co-infected patients. Ordinal regression analysis outperformed other noninvasive fibrosis prediction models. Longitudinal studies with paired biopsies will assist in refining the Ordinal Regression Index.

[Novel methods for the assessment of sensory, biomechanical and motor functions of the gastrointestinal tract]

The article gives a review of new methods in gastroenterology. The >>functional lumen imaging probe<< is a method used to evaluate the competence of sphincter regions during distension. The axial force probe can measure forces in the oesophagus during swallowing and give new information about patients with motor disorders of the oesophagus. The >>multimodal probe<< measures the sensory response to electrical, mechanical, thermal and chemical stimuli. Together with advanced modeling of the brain activity, these methods have increased our knowledge about the pathogenesis of sensory symptoms.

Do we really understand the role of the oesophagogastric junction in disease?

The role of the oesophago-gastric junction (OGJ) in gastro-oesophageal reflux disease is still not completely understood, and there is no clinically used method to assess the OGJ function in patients. Only indirect methods such as pH studies are carried out. The OGJ acts a valve controlling the flow of solids, liquids and gases between the oesophagus and the stomach. Manometry can determine if a sphincter is toned or relaxed; but, it cannot confirm that the sphincter region is actually open. Distension is a new technique for measuring function in the OGJ. By measuring the cross-sectional area through the narrow region in the junction during distension of a catheter mounted bag, much more information on the opening and closing patterns of the junction can be determined. This technique has already been demonstrated to show changes in the OGJ after surgical treatments for reflux disease. New measurement ideas around the concept of distending the OGJ offer new hope that a clinically useable test for compliance at the junction can be developed and could potentially help in determining appropriate therapy.