Technical note: Comparison of automated ribosomal intergenic spacer analysis and denaturing gradient gel electrophoresis to assess bacterial diversity in the rumen of sheep

The aim of this study was to compare automated ribosomal intergenic spacer analysis (ARISA) and denaturing gradient gel electrophoresis (DGGE) techniques to assess bacterial diversity in the rumen of sheep. Sheep were fed 2 diets with 70% of either alfalfa hay or grass hay, and the solid (SOL) and liquid (LIQ) phases of the rumen were sampled immediately before feeding (0 h) and at 4 and 8 h postfeeding. Both techniques detected similar differences between forages, with alfalfa hay promoting greater (P < 0.05) bacterial diversity than grass hay. In contrast, whereas ARISA analysis showed a decrease (P < 0.05) of bacterial diversity in SOL at 4 h postfeeding compared with 0 and 8 h samplings, no variations (P > 0.05) over the postfeeding period were detected by DGGE. The ARISA technique showed lower (P < 0.05) bacterial diversity in SOL than in LIQ samples at 4 h postfeeding, but no differences (P > 0.05) in bacterial diversity between both rumen phases were detected by DGGE. Under the conditions of this study, the DGGE was not sensitive enough to detect some changes in ruminal bacterial communities, and therefore ARISA was considered more accurate for assessing bacterial diversity of ruminal samples. The results highlight the influence of the fingerprinting technique used to draw conclusions on factors affecting ruminal bacterial diversity.

Safety of thiopurines and anti-TNF-α drugs during pregnancy in patients with inflammatory bowel disease

OBJECTIVES

The safety of thiopurines and anti-tumor necrosis factor-α (TNF-α) drugs during pregnancy remains controversial, as the experience with these drugs in this situation is limited. Our aim is to assess the safety of thiopurines and anti-TNF-α drugs for the treatment of inflammatory bowel disease (IBD) during pregnancy.

METHODS

Retrospective, multicenter study in IBD patients. Pregnancies were classified according to the therapeutic regimens during pregnancy or during the 3 months before the conception: non-exposed group, pregnancies exposed to thiopurines alone (group A), and pregnancies exposed to anti-TNF-α drugs (group B). An unfavorable Global Pregnancy Outcome (GPO) was considered if pregnancy developed with obstetric complications in the mother and in the newborn.

RESULTS

A total of 187 pregnancies in the group A, 66 pregnancies in the group B, and 318 pregnancies in the non-exposed group were included. The rate of unfavorable GPO was different among the three groups (31.8% in non-exposed group, 21.9% in group A, and 34.8% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). The rate of pregnancy complications was similar among the three groups (27.7% in non-exposed, 20.9% in group A, and 30.3% in group B). The rate of neonatal complications was different among the three groups (23.3% in non-exposed group, 13.9% in group A, and 21.2% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). In the multivariate analysis, the treatment with thiopurines (odds ratio = 0.6; 95% confidence interval = 0.4-0.9, P = 0.02) was the only predictor of favorable GPO, whereas maternal age >35 years at conception was the only predictor of unfavorable GPO. The treatment with anti-TNF-α drugs was not associated with an unfavorable GPO.

CONCLUSION

The treatment with thiopurines and anti-TNF-α drugs does not seem to increase the risk of complications during pregnancy and does seem to be safe for the newborn.

The influence of diet type (dairy versus intensive fattening) on the effectiveness of garlic oil and cinnamaldehyde to manipulate in vitro ruminal fermentation and methane production

The objective of this study was to evaluate the effects of increasing doses [0 (control: CON), 20, 60, 180 and 540 mg/L incubation medium] of garlic oil (GO) and cinnamaldehyde (CIN) on in vitro ruminal fermentation of two diets. Batch cultures of mixed ruminal microorganisms were inoculated with ruminal fluid from four sheep fed a medium-concentrate diet (MC; 50 : 50 alfalfa hay : concentrate) or four sheep fed a high-concentrate diet (HC; 15 : 85 barley straw : concentrate). Diets MC and HC were representative of those fed to dairy and fattening ruminants, respectively. Samples of each diet were used as incubation substrates for the corresponding inoculum, and the incubation was repeated on 4 different days (four replicates per experimental treatment). There were GO × diet-type and CIN × diet-type interactions (P < 0.001–0.05) for many of the parameters determined, indicating different effects of both oils depending on the diet type. In general, effects of GO were more pronounced for MC compared with HC diet. Supplementation of GO did not affect (P > 0.05) total volatile fatty acid (VFA) production at any dose. For MC diet, GO at 60, 180 and 540 mg/L decreased (P < 0.05) molar proportion of acetate (608, 569 and 547 mmol/mol total VFA, respectively), and increased (P < 0.05) propionate proportion (233, 256 and 268 mmol/mol total VFA, respectively), compared with CON values (629 and 215 mmol/mol total VFA for acetate and propionate, respectively). A minimum dose of 180 mg of GO/L was required to produce similar modifications in acetate and propionate proportions with HC diet, but no effects (P > 0.05) on butyrate proportion were detected. Methane/VFA ratio was reduced (P < 0.05) by GO at 60, 180 and 540 mg/L for MC diet (0.23, 0.16 and 0.10 mol/mol, respectively), and by GO at 20, 60, 180 and 540 mg/L for HC diet (0.19, 0.19, 0.16 and 0.08 mol/mol, respectively), compared with CON (0.26 and 0.21 mol/mol for MC and HC diets, respectively). No effects (P = 0.16–0.85) of GO on final pH and concentrations of NH3-N and lactate were detected. For both diet types, the highest CIN dose decreased (P < 0.05) production of total VFA, gas and methane, which would indicate an inhibition of fermentation. Compared with CON, CIN at 180 mg/L increased (P < 0.05) acetate proportion for the MC (629 and 644 mmol/mol total VFA for CON and CIN, respectively) and HC (525 and 540 mmol/mol total VFA, respectively) diets, without affecting the proportions of any other VFA or total VFA production. Whereas for MC diet CIN at 60 and 180 mg/L decreased (P < 0.05) NH3-N concentrations compared with CON, only a trend (P < 0.10) was observed for CIN at 180 mg/L with the HC diet. Supplementation of CIN up to 180 mg/L did not affect (P = 0.18–0.99) lactate concentrations and production of gas and methane for any diet. The results show that effectiveness of GO and CIN to modify ruminal fermentation may depend on diet type, which would have practical implications if they are confirmed in vivo.

Long-term durability of response to adalimumab in Crohn's disease

BACKGROUND

Adalimumab is an effective treatment for Crohn's disease (CD), but may also be associated with loss of response. Few reports provide insight into the durability of treatment of CD with adalimumab for periods longer than 12 months in clinical practice.

AIMS

To evaluate the long-term durability of adalimumab maintenance treatment and to identify predictive factors associated with loss of response.

METHODS

CD patients who initially responded to adalimumab were evaluated in a historical cohort study. Maintenance of long-term response was estimated using Kaplan-Meier analysis. Cox regression analysis was performed to identify potential predictive factors for loss of efficacy.

RESULTS

In all, 380 CD patients were included (mean age, 38 years; 52% female). Of these, 43% had ileocolic CD, 50% inflammatory CD, and 41% perianal CD. Median follow-up with adalimumab was 8 months (range, 4-75 months). The annual risk of loss of response to adalimumab was 18% per patient-year of follow-up. Twenty-eight percent of patients were anti-TNF-naïve and 72% anti-TNF-experienced. The loss of efficacy was 8% per patient-year of follow-up in the anti-TNF-naïve patients and 22% in the anti-TNF-experienced group (P < 0.01). In the multivariate analysis, the presence of extraintestinal manifestations (hazard ratio [HR] = 1.7; 95% confidence interval [CI] = 1.02-2.9) and previous experience with other anti-TNF agents (HR = 2.5,95% CI = 1.2-5.3) were associated with higher risk of loss of efficacy.

CONCLUSIONS

A relevant proportion of CD patients on long-term adalimumab lost response. The risk of loss of response was higher (more than 2-fold) in anti-TNF-experienced than in anti-TNF-naïve patients (22% vs. 8% per patient-year of treatment). Having extraintestinal manifestations seems to increase the risk of loss of efficacy.

Adalimumab induction and maintenance therapy for patients with ulcerative colitis previously treated with infliximab

BACKGROUND

The long-term efficacy of adalimumab in patients with ulcerative colitis is not well known.

AIM

To evaluate the short- and long-term outcomes of adalimumab in ulcerative colitis patients previously treated with infliximab.

METHODS

Patients with active ulcerative colitis were treated with adalimumab after failure of other therapies including infliximab. Short-term clinical response and remission were assessed at weeks 4 and 12. The proportion of patients who continued on adalimumab and the proportion of patients who remained colectomy free were assessed over the long term.

RESULTS

Clinical response at weeks 4 and 12 was achieved in 16 (53%) and 18 (60%) patients, respectively, and clinical remission was obtained in 3 (10%) and 8 (27%) patients, respectively. After a mean 48 weeks' follow-up, 15 patients (50%) continued on adalimumab. Six patients (20%) required colectomy. All patients who achieved clinical response at week 12 were colectomy free at long term.

CONCLUSIONS

Adalimumab was well tolerated and induced durable clinical response in many patients with otherwise medically refractory ulcerative colitis. Patients achieving clinical response at week 12 avoided colectomy over the long term.

Comparison of fermentation of diets of variable composition and microbial populations in the rumen of sheep and Rusitec fermenters. II. Protozoa population and diversity of bacterial communities

Four ruminally and duodenally cannulated sheep and 8 Rusitec fermenters were used to determine the effects of dietary characteristics on microbial populations and bacterial diversity. The purpose of the study was to assess how closely fermenters can mimic the differences between diets found in vivo. The 4 experimental diets contained forage to concentrate (F:C) ratios of 70:30 (high forage; HF) or 30:70 (high concentrate; HC) with either alfalfa hay (A) or grass hay (G) as the forage. Total bacterial numbers were greater in the rumen of sheep fed HF diets compared with those fed HC diets, whereas the opposite was found in fermenters. The numbers of cellulolytic bacteria were not affected by F:C ratio in any fermentation system, but cellulolytic numbers were 2.7 and 1.8 times greater in sheep than in fermenters for HF and HC diets, respectively. Neither total bacterial nor cellulolytic numbers were affected by the type of forage in sheep or fermenters. Decreasing F:C ratio increased total protozoa and Entodiniae numbers in sheep by about 29 and 25%, respectively, but it had no effect in fermenters. Isotrichidae and Ophryoscolecinae numbers in sheep were not affected by changing F:C ratio, but both disappeared completely from fermenters fed HC diets. Total protozoa and Entodiniae numbers were greater in sheep fed A diets than in those fed G diets, whereas the opposite was found in fermenters. Results indicate that under the conditions of the present study, protozoa population in Rusitec fermenters was not representative of that in the rumen of sheep fed the same diets. In addition, protozoa numbers in fermenters were 121 and 226 times lower than those in the sheep rumen for HF and HC diets, respectively. The automated ribosomal intergenic spacer analysis of the 16S ribosomal DNA was used to analyze the diversity of liquid- and solid-associated bacteria in both systems. A total of 170 peaks were detected in the automated ribosomal intergenic spacer analysis electropherograms of bacterial pellets across the full set of 64 samples, from which 160 were detected in at least 1 individual from each system (sheep or fermenter). Diversity of liquid-associated bacterial pellets was greater with G diets in fermenters but seemed to be unaffected by diet in sheep. Bacterial diversity in solid-associated bacteria pellets was greater for G diets compared with A diets in sheep and fermenters. Different conditions in the fermenters compared with sheep rumen might have caused a selection of some bacterial strains.

Liver dysfunction related to hepatitis B and C in patients with inflammatory bowel disease treated with immunosuppressive therapy

BACKGROUND

There is no information about the frequency of liver dysfunction in patients with inflammatory bowel disease (IBD) treated with immunosuppressants and infected with hepatitis B (HBV) and/or C virus (HCV).

AIM

To assess the influence of immunosuppressants on the course of HBV and HCV infection in IBD.

METHODS

Patients with IBD with HBV and/or HCV infection from 19 Spanish hospitals were included. Clinical records were reviewed for the type of immunosuppressant used, treatment duration, liver function tests and viral markers before, during and after each immunosuppressant. Logistic and Cox regression analysis were used to identify predictors of outcome.

RESULTS

162 patients were included; 104 had HBV markers (25 HBsAg positive) and 74 had HCV markers (51 HCV-RNA positive), and 16 patients had markers of both infections. Liver dysfunction was observed in 9 of 25 HBsAg positive patients (36%), 6 of whom developed hepatic failure. Liver dysfunction in HCV was observed in 8 of 51 HCV-RNA positive patients (15.7%), and only one developed hepatic failure. The frequency and severity of liver dysfunction was significantly higher in HBV-infected patients than in HCV-infected patients (p=0.045 and p=0.049, respectively). Treatment with ≥2 immunosuppressants was an independent predictor of HBV reactivation (OR 8.75; 95% CI 1.16 to 65.66). The majority of patients without reactivation received only one immunosuppressant for a short period and/or prophylactic antiviral treatment. No definite HBV reactivations were found in anti-HBc positive patients lacking HBsAg.

CONCLUSION

Liver dysfunction in patients with IBD treated with immunosuppressants is more frequent and severe in those with HBV than in HCV carriers and is associated with combined immunosuppression.

Evaluation of procedures for detaching particle-associated microbes from forage and concentrate incubated in Rusitec fermenters: efficiency of recovery and representativeness of microbial isolates

Three detachment procedures (DP) were evaluated for their ability to remove particle-associated microbes from digesta in Rusitec fermenters fed a 30:70 alfalfa hay:concentrate diet. Forage and concentrate were incubated in separate nylon bags, and incubation residues were treated independently. Microbial biomass was labeled with (15)NH(4)Cl. Treatments were 1) MET: residues were incubated at 38 degrees C for 15 min with saline solution (0.9% NaCl) containing 0.1% methylcellulose with continuous shaking; 2) STO: residues were mixed with cold saline solution and homogenized with a stomacher for 5 min at 230 revolutions per min; and 3) FRE: residues were immediately frozen at -20 degrees C for 72 h, thawed at 4 degrees C, mixed with saline solution, and subjected to STO procedure. Common to all treatments was storing at 4 degrees C for 24 h after the treatment, homogenization, filtration, and resuspension of residues 2 times in the treatment solutions. Microbial pellets were obtained by centrifugation, and microbial removal was estimated indirectly by measuring removal of (15)N. The PCR-single-stranded conformation polymorphism analysis of the 16S ribosomal DNA was used to analyze the similarity between microbial communities attached to the substrate and those in the pellet obtained after each DP. There were no feed x DP interactions (P = 0.16 to 0.96) for any variable, except for N content in microbial pellets (P = 0.02). Detaching efficiency (P = 0.004) and total recovery (P = 0.01) were affected by DP, with STO showing the greatest values (mean values across substrates of 64.1% for detaching efficiency and 58.3% for total recovery) and MET the least values (57.0 and 51.8%). Similarity index between the microbes attached to substrates and those in the pellets were affected (P = 0.02) by DP, with MET showing greater (P < 0.02) values (84.0 and 86.4% for forage and concentrate, respectively) than FRE (72.5 and 67.8%) and STO having intermediate values (77.1 and 82.4%). There were no differences (P = 0.70) among particle-associated microbe pellets in their N content, but MET pellets had greater (P < 0.05) (15)N enrichments than those obtained by STO and FRE. Although STO was the most effective method to detach ruminal microbes from concentrate and forage, MET produced pellets with the greatest similarity to the microbial communities attached to the substrates and therefore could be considered the most appropriate DP method for treating digesta from Rusitec fermenters.

Resource use in patients with Crohn's disease treated with infliximab

AIM

To estimate the impact of infliximab (IFX) on hospital resources for patients with Crohn's disease.

METHODS

Resource use data for at least 1 year before (B-IFX) and after (A-IFX) infliximab administration were retrospectively collected for all patients treated with IFX at the Hospital Cabueñes (Spain). Direct costs calculated were: hospital-stays, surgeries, out-patient visits, diagnostic and laboratory tests, pharmacological treatments, and day-care hospitalization for IFX administration.

RESULTS

Patients (n = 34; mean age at treatment: 43.6 years) with 9.8 and 4.3 years (B-IFX and A-IFX, respectively) had their costs estimated. Partial or complete response was achieved in 82% of patients. Total annual B-IFX costs per patient were Euro 4,464, of which 62.4% was for hospitalization, 3.1% for surgery, 8.7% for consultation visits, 16.2% for diagnostic and laboratory tests, and 9.6% for other treatments. Total annual A-IFX costs per patient were Euro 10,594; of which 6.4% was for hospitalization, 0.8% for surgery, 4.2% for consultation visits, 7.6% for diagnostic and laboratory tests, 5.5% for other treatments, and 75.5% for IFX and its administration. The primary cost item was hospitalization (Euro 2,783) during the B-IFX period as opposed to IFX itself (Euro 7,996) during the subsequent A-IFX period.

CONCLUSIONS

In routine practice, IFX appears to be an effective treatment by reducing hospital-stays, but increases overall budgetary cost for patients with Crohn's disease.

Efficacy and safety of short-term adalimumab treatment in patients with active Crohn's disease who lost response or showed intolerance to infliximab: a prospective, open-label, multicentre trial

BACKGROUND

The use of tumour necrosis factor antagonists has changed the therapeutic approach to Crohn's disease.

AIM

To determine response and remission rates associated with the 4-week induction phase of adalimumab treatment in patients with luminal and/or fistulizing Crohn's disease, who have lost response to or become intolerant of infliximab.

METHODS

In this multicentre, prospective, open-label, observational, 52-week study, 50 adults received an induction dose of adalimumab (160 mg at baseline followed by 80 mg at week 2).

RESULTS

Of the 36 patients with luminal Crohn's disease, 83% achieved clinical response [> or =70-point reduction in the Crohn's Disease Activity Index (CDAI) score] and 42% achieved clinical remission (CDAI score <150) at week 4. Of the 22 patients with fistulizing disease, five (23%) experienced fistula remission (complete closure of all fistulas that were draining at baseline), and nine (41%) experienced fistula improvement (> or =50% decrease in the number of fistulas that were draining at baseline) at week 4. Of the 19 adverse events, most [13 (68%)] were mild, and no serious or infectious adverse events occurred.

CONCLUSIONS

Adalimumab may be an effective alternative in patients with luminal and/or fistulizing Crohn's disease who have lost response to or become intolerant of infliximab.

Reliability of radiological and cosmetic measurements in hallux valgus

PURPOSE

To evaluate the reliability of angular, linear, and sesamoid position measurements on preoperative and postoperative radiographs in hallux valgus (HV), as well as cosmetic foot appearance.

MATERIAL AND METHODS

Radiographs and photographs from 100 patients undergoing HV surgery were evaluated by two independent observers.

RESULTS

Interobserver and intraobserver agreements for HV angle using coefficient of repeatability measures were 4.4 degrees and 3.7 degrees, respectively. Intraclass correlation coefficient measures within and between agreements were 0.97 for HV angle. For intermetatarsal distance, interobserver and intraobserver values were 0.90 and 0.94 when measuring from the midline of each metatarsal and 0.75 and 0.92 when measuring between cortices. Using the visual analog scale to evaluate esthetic appearance, interobserver and intraobserver agreements were 0.59 and 0.79, respectively. Sesamoid position values were also measured. Interobserver and intraobserver kappa values for preoperative and postoperative evaluations with two established methods (Mann or Smith) were 0.47 and 0.70 or 0.65 and 0.75, respectively.

CONCLUSION

Intraobserver reliability was higher than interobserver for intermetatarsal distance, cosmetics, and sesamoid position. Angular measurements were more accurate than linear. Esthetic evaluation was less reliable than radiographic, except in the case of sesamoid position measurements.

Granulocyteaphaeresis in steroid-dependent inflammatory bowel disease: a prospective, open, pilot study

BACKGROUND

Uncontrolled studies suggest that granulocyteaphaeresis might be useful in the management of active ulcerative colitis.

AIM

To assess the efficacy of granulocyteaphaeresis treatment in active steroid-dependent inflammatory bowel disease.

METHODS

We conducted a multicentre, prospective, open, pilot study in patients with steroid-dependent inflammatory bowel disease. All patients were started on 60 mg/day of prednisone; after 1 week, a five-session programme of granulocyteaphaeresis (once per week) was started. The steroid dose was tapered weekly if there was clinical improvement. Remission was defined as an inactive clinical activity index together with complete withdrawal of steroids at week 6. The patients were followed up for at least 6 months or until disease relapse.

RESULTS

Twenty-six patients (14 ulcerative colitis, 12 Crohn's disease) were included. More than a half had been previously treated with immunomodulators. Remission was achieved in 62 and 70% of ulcerative colitis and Crohn's disease, respectively. During a median follow-up of 12.6 months, six of eight ulcerative colitis patients maintained their clinical remission; however, only one Crohn's disease patient remained in remission after the first 6 months of follow-up.

CONCLUSIONS

Granulocyteaphaeresis is a safe treatment option in inflammatory bowel disease. A five-session programme of granulocyteaphaeresis seems to be efficient in the treatment of steroid-dependent ulcerative colitis, but not in Crohn's disease.

Chronic hepatitis B reactivation following infliximab therapy in Crohn's disease patients: need for primary prophylaxis

BACKGROUND

There is little information about the effect of infliximab on the clinical course of liver disease in Crohn's disease patients with concomitant hepatitis B virus (HBV) infection. Theoretically, immunosuppression induced by infliximab will facilitate viral replication which could be followed by a flare or exacerbation of disease when therapy is discontinued. There are no specific recommendations on surveillance and treatment of HBV before infliximab infusion. Two cases of severe hepatic failure related to infliximab infusions have been described in patients with rheumatic diseases.

PATIENTS AND METHODS

Hepatitis markers (C and B) and liver function tests were prospectively determined to 80 Crohn's disease patients requiring infliximab infusion in three hospitals in Spain.

RESULTS

Three Crohn's disease patients with chronic HBV infection were identified. Two of the three patients with chronic HBV infection suffered severe reactivation of chronic hepatitis B after withdrawal of infliximab therapy and one died. A third patient, who was treated with lamivudine at the time of infliximab therapy, had no clinical or biochemical worsening of liver disease during or after therapy. From the remaining 80 patients, six received the hepatitis B vaccine. Three patients had antibodies to both hepatitis B surface antigen (anti-HBs) and hepatitis B core protein (anti-HBc) with normal aminotransferase levels, and one patient had positive anti-hepatitis C virus (HCV) antibodies, negative HCV RNA, and normal aminotransferase levels. Except for the patients with chronic HBV infection, no significant changes in hepatic function were detected.

CONCLUSIONS

Patients with Crohn's disease who are candidates for infliximab therapy should be tested for hepatitis B serological markers before treatment and considered for prophylaxis of reactivation using antiviral therapy if positive.

Chronic hepatitis B reactivation following infliximab therapy in Crohn's disease patients: need for primary prophylaxis

BACKGROUND

There is little information about the effect of infliximab on the clinical course of liver disease in Crohn's disease patients with concomitant hepatitis B virus (HBV) infection. Theoretically, immunosuppression induced by infliximab will facilitate viral replication which could be followed by a flare or exacerbation of disease when therapy is discontinued. There are no specific recommendations on surveillance and treatment of HBV before infliximab infusion. Two cases of severe hepatic failure related to infliximab infusions have been described in patients with rheumatic diseases.

PATIENTS AND METHODS

Hepatitis markers (C and B) and liver function tests were prospectively determined to 80 Crohn's disease patients requiring infliximab infusion in three hospitals in Spain.

RESULTS

Three Crohn's disease patients with chronic HBV infection were identified. Two of the three patients with chronic HBV infection suffered severe reactivation of chronic hepatitis B after withdrawal of infliximab therapy and one died. A third patient, who was treated with lamivudine at the time of infliximab therapy, had no clinical or biochemical worsening of liver disease during or after therapy. From the remaining 80 patients, six received the hepatitis B vaccine. Three patients had antibodies to both hepatitis B surface antigen (anti-HBs) and hepatitis B core protein (anti-HBc) with normal aminotransferase levels, and one patient had positive anti-hepatitis C virus (HCV) antibodies, negative HCV RNA, and normal aminotransferase levels. Except for the patients with chronic HBV infection, no significant changes in hepatic function were detected.

CONCLUSIONS

Patients with Crohn's disease who are candidates for infliximab therapy should be tested for hepatitis B serological markers before treatment and considered for prophylaxis of reactivation using antiviral therapy if positive.

Serological markers of hepatitis A, B and C in first year student nurses

OBJECTIVE

To know the prevalence of serological markers of hepatitis A, B and C virus in first year student nurses.

SETTING

A transversal study of prevalence.

SUBJECTS AND METHODS

81 first year student nurses, mean age 20.6 years (18-37, S.D. 3.8), with demographic, epidemiologic and clinical variables, performing liver enzymes, anti-HAV IgG, anti-HBcore and anti-HCV.

RESULTS

The anti-HAV IgG was positive in 9 students (11.1%), with a prevalence of 6.7% between 17 and 19 years (C.I.95% 1.7 to 19.3%), 8.7% between 20 and 22 years (C.I.95% 1.5 to 29.5%), 20% between 23 and 25 years (C.I.95% 10.5 to 70.1%), and 37.5% (C.I.95% 10.2 to 74.1) in those over 25 years (p < 0.001). No other significative variables existed according to age-group. Regarding hepatitis B virus, of the 65 not previously vaccinated, only 1 (1.5%, C.I.95% 0.08 to 9.4%) was immunized, and there were no cases of HBsAg positive. The anti-VHC was positive in one case (1.2%, C.I.95% 0.06 to 7.6%), RIBA indeterminate and with normal ALT. Only one student (1.2%) showed increased transaminase values, attributed to liver steatosis. None of the students had suffered any episode of acute clinic hepatitis.

CONCLUSIONS

The anti-HAV IgG prevalence in first year student nurses in our area is very low, and it is not necessary to carry out prevacunal screening. The low prevalence of anti-Hbcore also rejects a similar screening with respect to HBV. There were no HBsAg or anti-HCV positive cases, but it should not be the cause of forgetting to take the universal precautions or giving a false sensation of security.

[The prevalence of hepatitis A, B and C viral markers in the population of Gijón between 26 and 65 years old]

The aim of this study was to know the prevalence of hepatitis A, B and C markers in an adult population in Gijón, Spain. A randomized, transversal sample according to the census was made in a population between 26 and 65 years of age in Gijón, analyzing demographic, epidemiologic and clinical variables, liver function tests, anti-HAV IgG, anti-HBcore and anti-HCV. Of the 476 individuals included a census error was detected in 26 (5.5%) and 340 (71.4%) were studied. Of these anti-HAV IgG was positive in 210 (61.8%) with prevalences of 17.9% from 26 to 30 years (CI: 95%, 11.1%-27.4%), 54.7% from 31 to 35 years (CI: 95%, 41.8%-67%), 73.6% from 36 to 40 years (CI: 95%, 59.4%-84.3%) and 93% (CI: 95%, 86.7%-96.5%) above 40 years of age (p < 0.001). No other significant variables were found adjusted by age groups. With regard to HBV, of the 331 unvaccinated cases, 35 (10.6, CI 95%, 7.6%-14.5%) presented immune markers and 4 (1.2% CI: 95%, 0.4%-3.3%) HBsAg positivity, with all having normal ALT and no viral replication. Anti-HCV was positive in 1.7% (CI: 95%, 0.7-3.9%), being significantly related to IVDA or tattoos. Hypertransaminasemias were detected in 18 (5.3%) being attributed to virus C (27.8%), alcoholism (27.8%) or obesity (44.4%). History of clinical manifestations of acute hepatitis was collected in 9.7% of the cases with no memory of the episode in 84.3% of the anti-HAV IgG positive cases, 79.5% of the anti-HBcore positive cases and 83.3% of the anti-HCV positive cases. The current curve of prevalence of anti-HAV IgG in the Gijón population varies in the decade from 30 to 40 years in age ranging from values discarding prevaccination screening under the age of 30 to levels of minimum susceptibility to infection above the age of 40. The low prevalence of anti-HBcore underestimates its use as prevaccination screening versus HBV in the population of Gijón. The prevalences of HBsAg or anti-HCV thereby make this area a zone of intermediate endemicity, with around 3% of the population being chronically infected by one of these viruses.

Ankle arthroscopy under local and general anaesthesia for diagnostic evaluation and treatment

Improvements in techniques and instrumentation are extending the diagnostic and therapeutic indications for ankle arthroscopy. We aimed to study the diagnostic and therapeutic benefits and complication rate from 112 consecutive ankle arthroscopies performed between 1991 and 1994 under local and general anaesthesia. One-hundred and twelve outpatient ankle arthroscopies were performed in 72 male and 37 female patients, 16-64 years old. The patients were comparable in terms of gender and age in the arthroscopies done under local (n = 69) and the arthroscopies done under general anaesthesia (n = 43). The indications for surgery were pain in 75%, instability in 15%, limited function in 7% and swelling in 4%, and these criteria were similar in both groups. Antero-medial and anterolateral portals were used in all cases. No tourniquet was used and an external distractor was used in one case only. In 64 cases (57%) surgery was performed and included synovectomy, removal of loose bodies, shaving drilling of osteochondritic or other cartilage lesions, resection of impinging osteophytes, fibrosis and meniscoid lesions. In 95 ankles (85%) a definite diagnosis was established. Comparable diagnostic and therapeutic potentials were found between local and general anaesthesia. The complication rate was low. One patient who was operated on under general anaesthesia sustained a deep infection, and three suffered minor superficial nerve injuries. In conclusion, ankle arthroscopy may be performed under local or general anaesthesia with similar diagnostic value and with a low complication rate.

[The prevalence of markers for the hepatitis A and B viruses in the population of Gijón between 6 and 25 years old]

BACKGROUND

The aim of this study was to know the prevalence of previous infection markers for hepatitis A and B viruses in a pediatric-juvenile population from Gijón, Spain.

PATIENTS AND METHODS

A representative (according to the census) transversal randomized sample of a population from 6 to 25 years in age from Gijón, Spain, was included in the study analyzing demographic, epidemiologic and clinical variables, liver tests, anti-HAV IgG and anti-HBc.

RESULTS

Of the 630 individuals selected a demographic error was detected in 28 (4.4%) and 453 subjects were studied (71.9%) in whom the anti-HAV IgG was positive in 37 cases (8.75% of prevalence adjusted for age), with 4.4% (12/271) (CI 95% 2.3%-7.6%) for the younger cases and 13.7% (25/182) (CI 95% 9.1%-19.6%) in the group ranging from 18 to 25 years in age (p < 0.001). No anti-HAV IgG positive case was detected in the population under the age of 10 years. Among the young adults the prevalence of anti-HAV IgG positive cases was higher in those born in the south of Spain (2/6, 33.3%) (CI 95% 4.3%-77.7%) with respect to those from the northern regions of Spain (9/259, 3.5%) (CI 95% 1.6%-6.4%). (p = 0.02). With respect to HBV markers, of the 433 unvaccinated cases, 6 (1.4%) presented markers of past infection and 2 (0.46%) HBsAg positivity. Both had normal serum ALT without viral replication. Six cases of hypertransaminasemia levels (1.3%) were detected all being related with obesity or alcoholism. All the cases with previous acute clinical hepatitis were found to be anti-HAV IgG positive and anti-HBc negative.

CONCLUSIONS

The current prevalence of anti-HAV IgG in the population from 6 to 25 years from Gijón, Spain is very low and given the high degree of susceptibility (86%) for HAV infection in the young adult population (18-25 years) the implementation of vaccination programs is recommended even without previous serologic screening. The low prevalence of anti-Hbc would also undervalue its use as prevaccination screening against HB in this geographical area.

[Campylobacter fetus, an infrequent microbe, as a cause of spontaneous bacterial peritonitis in cirrhosis]

Campylobacter fetus has been implicated in the etiology of sepsis and bacteriemias in immunosupressed subjects. In a few cases, it has also been reported to be responsible for spontaneous bacterial peritonitis in cirrhotic patients. We describe the clinical picture of a woman with terminal liver cirrhosis who had bacteriemia and spontaneous bacterial peritonitis caused by this agent. We argue about the history of cleansing enemas and their probable role in the development of the infection. We stress the excellent response to the antibiotic treatment.

[Ascitic peritonitis due to Candida albicans]

We report a case of spontaneous peritonitis due to Candida albicans, in a diabetic patient with alcoholic liver cirrhosis, ascites, gastrointestinal bleeding from esophageal varices, sepsis, renal failure and encephalopathy. These factors, added to prolonged antibiotic therapy and instrumental manipulations, could have resulted in the colonization by Candida, usually described in secondary peritonitis, but perhaps underdiagnosed in cirrhotic patients with spontaneous peritonitis and severe multiorgan failure.