Intravenous Hemin, a potential heme oxygenase-1 activator, does not protect from post-ERCP acute pancreatitis in humans: Results of a randomized multicentric multinational placebo-controlled trial

OBJECTIVE

Hemin, a heme oxygenase 1 activator has shown efficacy in the prevention and treatment of acute pancreatitis in mouse models. We conducted a randomized controlled trial (RCT) to assess the protective effect of Hemin administration to prevent post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in patients at risk.

METHODS

In this multicenter, multinational, placebo-controlled, double-blind RCT, we assigned patients at risk for PEP to receive a single intravenous dose of Hemin (4 mg/kg) or placebo immediately after ERCP. Patients were considered to be at risk on the basis of validated patient- and/or procedure-related risk factors. Neither rectal NSAIDs nor pancreatic stent insertion were allowed in randomized patients. The primary outcome was the incidence of PEP. Secondary outcomes included lipase elevation, mortality, safety, and length of stay.

RESULTS

A total of 282 of the 294 randomized patients had complete follow-up. Groups were similar in terms of clinical, laboratory, and technical risk factors for PEP. PEP occurred in 16 of 142 patients (11.3%) in the Hemin group and in 20 of 140 patients (14.3%) in the placebo group (p = 0.48). Incidence of severe PEP reached 0.7% and 4.3% in the Hemin and placebo groups, respectively (p = 0.07). Significant lipase elevation after ERCP did not differ between groups. Length of hospital stay, mortality and severe adverse events rates were similar between groups.

CONCLUSION

We failed to detect large improvements in PEP rate among participants at risk for PEP who received IV hemin immediately after the procedure compared to placebo.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov number, NCT01855841).

Acute upper gastrointestinal bleeding in cirrhosis: changes and advances over the past two decades

BACKGROUND AND AIMS

Few studies have compared two or more cohorts of cirrhotic patients admitted for upper gastrointestinal bleeding (UGIB) several decades apart. Our aim was to compare epidemiological, clinical, therapeutic and prognostic characteristics of UGIB (whatever the source) in two cohorts of cirrhotic patients admitted to the emergency room of the same general hospital 2 decades apart.

METHODS

One-hundred cases of UGIB in cirrhotic patients consecutively admitted between 1984 and 1990 (cohort A) were compared with 100 similar cases admitted between 2004 and 2009 (cohort B).

RESULTS

The sex ratio (M/F: 2/1), mean age (approximately 55Y) and the proportion of patients with alcoholic cirrhosis (approximately 80%) did not change. Mean Child-Pugh score and the proportion of patients in Child-Pugh stage C increased from 7.6 and 19% in cohort A to 8.8 and 35% in cohort B (p < 0.001). Therapeutic intervention was performed during initial endoscopy in 13 cases from cohort A and 50 from cohort B (p < 0.001), respectively. The number of transfused patients (85 in cohort A, 58 in cohort B) and the number of red blood cell units administered on the first day (median: 4 in cohort A, 2 in cohort B) were significantly decreased in cohort B (p < 0.001). The rate of rebleeding (45 in cohort A, 11 in cohort B), the need for rescue surgery (8 in cohort A, 0 in cohort B) and the in-hospital mortality (24 in cohort A, 9 in cohort B) significantly decreased in the more recent cohort (p < 0.005).

CONCLUSION

This study demonstrated that several characteristics of cirrhotic patients admitted with UGIB have changed over the past 2 decades. Above all, outcome has improved despite an increase in the severity of cirrhosis.

The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity

In industrialized countries, surgical gastroplasty is performed more and more frequently in patients with morbid obesity. The aims of this prospective study were to determine the incidence of upper gastrointestinal lesions in obese patients and to assess the place of digestive endoscopy in symptomatic patients after gastroplasty. A consecutive group of 159 obese patients were studied before and after vertical banded gastroplasty. In the preoperative evaluation, reflux esophagitis and gastroduodenal lesions were endoscopically observed in 31% and 37% of the patients, respectively. Interestingly, the majority of the obese patients with upper gastrointestinal lesions were asymptomatic. In the postoperative follow-up period, 55 of the 159 patients complained of upper gastrointestinal symptoms such as vomiting (72%), esophageal reflux (17%), and epigastric pain (3%). Stenosis of the outlet of the gastric pouch was described in 40 of the 55 symptomatic patients. Esophagitis was observed in 60% of these patients. Endoscopic dilation using Savary bougies or TTS balloon was successfully performed in all the patients with symptomatic stenosis of the gastric outlet. Food impaction was endoscopically removed in four patients. Thus, we recommend performing an upper gastrointestinal endoscopy in obese patients who are candidates for surgical gastroplasty because of the high incidence of upper gastrointestinal peptic lesions. Endoscopy is also helpful in patients with digestive disorders occurring after gastroplasty in order to define and to treat the lesions.

Prognostic evaluation of patients with parenchymal cirrhosis. Proposal of a new simple score

BACKGROUND/AIMS

The current shortage of organs makes it desirable to establish the prognosis of patients with cirrhosis in order to assess priority for liver transplantation.

METHODS

We compared the utility of two exogenous tests (aminopyrine breath test and lidocaine metabolization test), two clinical parameters (encephalopathy, ascites), 18 endogenous tests and five scores (Pugh, Merkel, Orrego, Adler, Pignon) for predicting 1-year mortality in patients with parenchymal cirrhosis. Retrospective (n=49 out of 63 patients) and prospective (n=38 out of 46 patients) series were included. Univariate, multivariate, receiver operator curves and survival curves were employed.

RESULTS

We found that endogenous tests were more discriminant than exogenous tests. The best parameters of the univariate analysis (encephalopathy, bilirubin, alkaline phosphatase, cholinesterase and bile acids) and their 25th and 75th percentiles were included in an additive new score which turned out to be superior to the five other scores. Prospectively, the sensitivity of our new score compared to the Pugh score was 82% versus 95% (NS) and the specificity was 89% versus 56% (p<0.01).

CONCLUSIONS

Our new simple score appears to be very powerful for predicting prognosis at 1 year for patients with cirrhosis and should be evaluated in other centers.

Early defibrillation by EMTs: the Brussels experience

Considering that in Brussels the first-aid ambulance team reaches the patient in cardiac arrest 10 min before the physician-manned ambulance, we instituted a feasibility study of early defibrillation by emergency medical technicians (EMTs). Three hundred EMTs received a 20-h automatic external defibrillation (AED) training course followed by a refresher course every 6 months. Of 316 cardiac arrests included in this study, asystole was encountered in 53% and ventricular fibrillation/ventricular tachycardia (VF/VT) in 33% of the cases on arrival of the EMTs. In the VF/VT group, defibrillation was performed by EMTs with a Laerdal Heartstart 7-9 min before the medical team arrived. The overall cardiac arrest survival rate improved from 7% in 1989 to 19% in 1992. However, the long-term survival rate (14/105) of ventricular fibrillation remained low because of excessive delays in emergency medical service (EMS) access and in early ACLS. In conclusion, this work shows that in Brussels: (1) early defibrillation of cardiac arrest victims in VF is feasible by EMTs when a training and a follow-up program are implemented; (2) the weakest link of the chain of survival is the early EMS access, and the early ACLS; and (3) AED program increases the interest and the efficacy of EMTs and medical teams in the management of cardiac arrests.

[Ewing's sarcoma: literature review and presentation of 4 cases]

Ewing's sarcoma occurs most often in young males of caucasian type and affects the medio-diaphysis of a long bone of the lower extremity, the pelvis and the humerus. Radiologically there is bone destruction, onion skin appearance, a Codman triangle and extension into the surrounding soft tissues. Microscopically, this tumor is composed of small round cells and it can be differentiated from non Hodgkin lymphoma, metastatic neuroblastoma and embryonal rhabdomyosarcoma. Recent immunological studies suspect a neuroectodermal origin. Ewing's sarcoma growths rapidly and spreads to lung and other bone locations. Without treatment, survival at 5 years is less than 5%. The actual therapeutic approach is multidisciplinary including surgery, chemotherapy and if necessary radiotherapy. With this approach actual survival rates at 5 years reaches 75%.