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Janssen R, Ariëns M, van Genugten J, Jacobi L, Koek G. Complex Dysautonomia in a Patient With Cerebral Cavernous Malformations Due to a KRIT1 Pleiotropic Gene Mutation. Cureus 2024; 16:e55202. [PMID: 38425333 PMCID: PMC10902799 DOI: 10.7759/cureus.55202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/02/2024] Open
Abstract
Dysautonomia is a disruption of the body's autonomic processes. Symptoms vary among patients, depending on the underlying disease pathways. Given that symptoms can affect all organ functions, dysautonomia often significantly impacts quality of life. However, due to its complex and varied presentation, early recognition of dysautonomia remains a challenge, yet it is crucial for improving patient outcomes. We report a case of a patient with a KRIT1 mutation presenting with dysautonomia causing urological, sexual, and bowel dysfunction. We hypothesize that the patient's symptoms are due to a pontine cavernous malformation (CM) caused by the KRIT1 mutation. A literature review was conducted to establish a link between pontine CM and dysautonomia.
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Affiliation(s)
- Roel Janssen
- Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, NLD
| | - Maxime Ariëns
- Department of Primary Care Medicine, Radboud University Medical Center, Nijmegen, NLD
| | | | - Linda Jacobi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, NLD
| | - Ger Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, NLD
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Koek G, Schmitz SM, Bednarsch J, Heise D, Longerich T, Bakers F, Trautwein C, Luedde T, Ulmer TF, Neumann UP. Living-Donor Liver Transplantation for a Large Hepatocellular Carcinoma in a Genetically Identical Twin Sister. Z Gastroenterol 2024; 62:56-61. [PMID: 38195109 PMCID: PMC10783995 DOI: 10.1055/a-2214-1712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Indexed: 01/11/2024]
Abstract
Hepatocellular carcinoma (HCC) is, to date, the most common malignant tumor of the liver and is commonly staged with the Milan criteria. While deceased-donor liver transplantations (DDLT) are reserved for patients within the Milan criteria, living-donor liver transplantation (LDLT) might be a curative option for patients outside the Milan criteria. We here report a case of a 32-year-old woman who developed a giant, unresectable HCC out of a hepatocellular adenoma (HCA) after a pregnancy. The genetically identical twin sister donated her left hemi-liver after ethical approval and preoperative screening. No long-term immunosuppressive therapy was necessary, and after more than eight years, both are in perfect health and the recipient gave birth to a second child. This case shows that in certain situations large HCCs outside the standard criteria can be cured by LT. Careful evaluation of both donor and recipient should be performed for indications like this to assure optimal clinical outcome.
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Affiliation(s)
- Ger Koek
- Department of Internal Medicine, Division of Gastroenterology/Hepatology, Maastricht UMC+, Maastricht, Netherlands
| | - Sophia M. Schmitz
- General-, Visceral and Transplantation Surgery, Universitätsklinikum Essen, Essen, Germany
- General-, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- General-, Visceral and Transplantation Surgery, Universitätsklinikum Essen, Essen, Germany
- General-, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniel Heise
- General-, Visceral and Transplantation Surgery, Universitätsklinikum Essen, Essen, Germany
- General-, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Thomas Longerich
- Institute of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Frank Bakers
- Department of Radiology, Maastricht UMC+, Maastricht, Netherlands
| | - Christian Trautwein
- Department of Gastroenterology Metabolic Disorders and Internal Intensive Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Tom Florian Ulmer
- General-, Visceral and Transplantation Surgery, Universitätsklinikum Essen, Essen, Germany
- General-, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Maastricht UMC+, Maastricht, Netherlands
| | - Ulf Peter Neumann
- General-, Visceral and Transplantation Surgery, Universitätsklinikum Essen, Essen, Germany
- General-, Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Maastricht UMC+, Maastricht, Netherlands
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Papadakis S, Anastasaki M, Gergianaki I, Koek G, Mendive J, Anastasiou F, Heyens L, Garcia-Retortillo M, Muris J, Lionis C. Development and implementation of a continuing medical education program on non-alcoholic fatty liver disease for primary care practitioners in Europe. Front Med (Lausanne) 2023; 10:1034626. [PMID: 37035308 PMCID: PMC10077524 DOI: 10.3389/fmed.2023.1034626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/09/2023] [Indexed: 04/11/2023] Open
Abstract
Background Primary care has a crucial role to play in the prevention, early detection, referral, and risk factor management of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFLD/NASH). In 2021, a team of European collaborators developed a continuing medical education (CME) program on NAFLD/NASH that consolidates evidence and clinical best practices tailored to the primary care setting. This article reports on the methodology used to design and develop the CME and the results of a feasibility study. Methods An expert advisory group representing both European specialists and general practitioners supported the design of the CME to be implemented in three European settings (Greece, Spain, and Netherlands). The CME features four training modules and problem-based learning using clinical case studies. The CME was tested regarding feasibility and acceptability among a sample of primary care providers (PCPs) in Greece (n = 28) with measurements occurring before, immediately after, and 1 month following the training. Outcome measures included satisfaction with the CME, changes in PCPs' knowledge, attitudes, confidence, and self-reported clinical practices related to NAFLD/NASH. Results The CME is available as an open-access e-learning course on the European Society for Primary Care Gastroenterology education platform in English, Greek, Spanish, and Dutch. The feasibility study documented high levels of satisfaction, with 96% of PCPs reporting they were extremely or very satisfied with the overall training. Statistically significant increases in PCPs' confidence in NAFLD/NASH-related clinical practices were documented between the pre- and post-assessments. At the follow-up, 62% of GPs reported that the CME had changed their clinical practices related to NAFLD/NASH to a great extent. Conclusion This CME intervention developed by experts and tailored to PCPs in European settings may serve as an asset for increasing knowledge, confidence, and practice behaviors related to NAFLD/NASH.
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Affiliation(s)
- Sophia Papadakis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Marilena Anastasaki
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Irini Gergianaki
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Ger Koek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism-NUTRIMM, aastricht University, Maastricht, Netherlands
| | - Juan Mendive
- La Mina Primary Health Care Centre - IDIAP Jordi Gol, Barcelona, Spain
- European Society for Primary Care Gastroenterology, London, United Kingdom
| | - Foteini Anastasiou
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece
- European Society for Primary Care Gastroenterology, London, United Kingdom
| | - Leen Heyens
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism-NUTRIMM, aastricht University, Maastricht, Netherlands
- Faculty of Medicine and Health Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jean Muris
- European Society for Primary Care Gastroenterology, London, United Kingdom
- Department of Family Medicine, CAPHRI Research Institute, Maastricht University, Maastricht, Netherlands
| | - Christos Lionis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete, Greece
- European Society for Primary Care Gastroenterology, London, United Kingdom
- *Correspondence: Christos Lionis,
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Gergianaki I, Anastasaki M, Papadaki S, Anastasiou F, Koek G, Leen H, Mendive J, Muris J, Lionis C. Heath literacy, illness perception and NAFLD/NASH awareness in primary care patients in Crete, Greece. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab165.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Patient health literacy (HL), illness perception and awareness are key factors driving health behaviour. This observational study aims to assess the level of HL, illness perception and awareness about non-alcoholic fatty liver disease (NAFLD)/steatohepatitis (NASH) in high-risk primary care (PC) patients in Greece, Spain and the Netherlands.
Methods
Eligibility criteria included: 1) aged ≥50 years, and 2) obesity, and/or metabolic syndrome, and/or diabetes. Patients consecutively visiting PC practices completed a questionnaire assessing socio-demographic characteristics and health habits. HL, illness perception and NAFLD/NASH awareness were assessed using the European Health Literacy Survey Questionnaire, the Brief Illness Perception Questionnaire and the Public Awareness of NAFLD Questionnaire respectively.
Results
Data are available at this moment from the Greek setting. Among the Greek participants (N = 141, 53.2% females, mean age 66 years) 66.7% had diabetes, 78% obesity and 71.6% metabolic syndrome, with 22.7% reporting active smoking. Most (71.6%) had heard about NAFLD by their personal physician. Obesity (78%), excess alcohol intake (45.8%), lack of exercise (38.7%) and diabetes (32.4%) were recognized as the commonest determinants of fatty liver disease, while 78% were aware of ultrasound as the main diagnostic modality and 47% did not know whether there is an available treatment. Only 39% of the participants find information of their treatments easily.
Conclusions
Our preliminary results show that the majority of patients seem to be aware about NAFLD/NASH and their determinants. It's alarming that a lot do not know about treatment, although they are high-risk.
Key messages
Our preliminary results show that the majority of patients seem to be aware about NAFLD/NASH and their determinants. It’s alarming that a lot of patients do not know about their treatment, although they are high-risk.
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Affiliation(s)
- I Gergianaki
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - M Anastasaki
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - S Papadaki
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - F Anastasiou
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - G Koek
- Department of Family Medicine and Department of Gastroenterogy, Maastricht University and Maastricht University Medical Centre, Maastricht, Netherlands
| | - H Leen
- Department of Family Medicine and Department of Gastroenterogy, Maastricht University and Maastricht University Medical Centre, Maastricht, Netherlands
| | - J Mendive
- La Mina Primary Health Care Centre, IDIAP Jordi Gol, Barcelona, Spain
- European Society for Primary Care Gastroenterology, London, UK
| | - J Muris
- Department of Family Medicine and Department of Gastroenterogy, Maastricht University and Maastricht University Medical Centre, Maastricht, Netherlands
| | - C Lionis
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
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Wisse E, Braet F, Shami GJ, Zapotoczny B, Vreuls C, Verhaegh P, Frederik P, Peters PJ, Olde Damink S, Koek G. Fat causes necrosis and inflammation in parenchymal cells in human steatotic liver. Histochem Cell Biol 2021; 157:27-38. [PMID: 34524512 PMCID: PMC8755686 DOI: 10.1007/s00418-021-02030-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 02/07/2023]
Abstract
Adapted fixation methods for electron microscopy allowed us to study liver cell fine structure in 217 biopsies of intact human livers over the course of 10 years. The following novel observations and concepts arose: single fat droplets in parenchymal cells can grow to a volume four times larger than the original cell, thereby extremely marginalizing the cytoplasm with all organelles. Necrosis of single parenchymal cells, still containing one huge fat droplet, suggests death by fat in a process of single-cell steatonecrosis. In a later stage of single-cell steatonecrosis, neutrophils and erythrocytes surround the single fat droplet, forming an inflammatory fat follicle indicating the apparent onset of inflammation. Also, fat droplets frequently incorporate masses of filamentous fragments and other material, most probably representing Mallory substance. No other structure or material was found that could possibly represent Mallory bodies. We regularly observe the extrusion of huge fat droplets, traversing the peripheral cytoplasm of parenchymal cells, the Disse space and the endothelium. These fat droplets fill the sinusoid as a sinusoidal lipid embolus. In conclusion, adapted methods of fixation applied to human liver tissue revealed that single, huge fat droplets cause necrosis and inflammation in single parenchymal cells. Fat droplets also collect Mallory substance and give rise to sinusoidal fat emboli. Therefore, degreasing of the liver seems to be an essential therapeutic first step in the self-repairing of non-alcoholic fatty liver disease. This might directly reduce single-cell steatotic necrosis and inflammation as elements in non-alcoholic steatohepatitis progression.
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Affiliation(s)
- Eddie Wisse
- Division of Nanoscopy, University of Maastricht Multimodal Molecular Imaging Institute, Maastricht, 6229, The Netherlands.
| | - Filip Braet
- School of Medical Sciences (Discipline of Anatomy and Histology) & Australian Centre for Microscopy & Microanalysis, The University of Sydney, Sydney, NSW, 2006, Australia.
| | - Gerald J Shami
- School of Medical Sciences (Discipline of Anatomy and Histology) & Australian Centre for Microscopy & Microanalysis, The University of Sydney, Sydney, NSW, 2006, Australia
| | | | - Celien Vreuls
- Department of Pathology, Utrecht University Medical Centre, Utrtecht, The Netherlands
| | - Pauline Verhaegh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, 6229 HX, Maastricht, The Netherlands
| | - Peter Frederik
- Emeritus of Maastricht University, Jekerstraat 39, 6211 NS, Maastricht, The Netherlands
| | - Peters J Peters
- Division of Nanoscopy, University of Maastricht Multimodal Molecular Imaging Institute, Maastricht, 6229, The Netherlands
| | - Steven Olde Damink
- Department of Surgery, Maastricht University Medical Center, 6229 HX, Maastricht, The Netherlands
| | - Ger Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, 6229 HX, Maastricht, The Netherlands
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Basnayake C, Geeraerts A, Pauwels A, Koek G, Vaezi M, Vanuytsel T, Tack J. Systematic review: duodenogastroesophageal (biliary) reflux prevalence, symptoms, oesophageal lesions and treatment. Aliment Pharmacol Ther 2021; 54:755-778. [PMID: 34313333 DOI: 10.1111/apt.16533] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/20/2021] [Accepted: 07/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The prevalence of duodenogastroesophageal reflux (DGER) and its effect on symptoms and oesophageal lesions in gastroesophageal reflux disease (GERD) is unclear. AIMS To conduct a systematic review to determine the prevalence of DGER among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER. METHODS We searched Pubmed and MEDLINE for full text, English language articles until October 2020 that evaluated DGER prevalence among patients with GERD, the effect of DGER on symptoms and oesophageal lesions, and the treatment of DGER. RESULTS We identified 3891 reports and included 35 which analysed DGER prevalence in GERD, 15 which evaluated its effect in non-erosive reflux disease (NERD), 17 on erosive oesophagitis, 23 in Barrett's, and 13 which evaluated the treatment of DGER. The prevalence of DGER, when evaluated by Bilitec, among all GERD patients ranged from 10% to 97%, in NERD 10%-63%, in erosive oesophagitis 22%-80% and in Barrett's 50%-100%. There were no differences in the presence or degree of DGER among patients who were asymptomatic or symptomatic on proton pump inhibitors (PPI). The most commonly evaluated treatments for DGER were PPIs and DGER reduced post-PPI therapy in all studies. CONCLUSIONS The prevalence of DGER increased with more advanced oesophageal lesions and did not explain persisting symptoms among patients taking PPI therapy. PPIs appear to be effective in the treatment of DGER. DGER remains an important consideration in patients with GERD and future therapies deserve more study.
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Affiliation(s)
- Chamara Basnayake
- Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium.,St Vincent's Hospital & University of Melbourne, Melbourne, VIC, Australia
| | - Annelies Geeraerts
- Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ans Pauwels
- Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ger Koek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michael Vaezi
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tim Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Translational Research Center for Gastrointestinal Disorders (TARGID), Katholieke Universiteit Leuven, Leuven, Belgium
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Shami GJ, Cheng D, Verhaegh P, Koek G, Wisse E, Braet F. Three-dimensional ultrastructure of giant mitochondria in human non-alcoholic fatty liver disease. Sci Rep 2021; 11:3319. [PMID: 33558594 PMCID: PMC7870882 DOI: 10.1038/s41598-021-82884-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/25/2021] [Indexed: 12/16/2022] Open
Abstract
Giant mitochondria are peculiarly shaped, extremely large mitochondria in hepatic parenchymal cells, the internal structure of which is characterised by atypically arranged cristae, enlarged matrix granules and crystalline inclusions. The presence of giant mitochondria in human tissue biopsies is often linked with cellular adversity, caused by toxins such as alcohol, xenobiotics, anti-cancer drugs, free-radicals, nutritional deficiencies or as a consequence of high fat Western diets. To date, non-alcoholic fatty liver disease is the most prevalent liver disease in lipid dysmetabolism, in which mitochondrial dysfunction plays a crucial role. It is not well understood whether the morphologic characteristics of giant mitochondria are an adaption or caused by such dysfunction. In the present study, we employ a complementary multimodal imaging approach involving array tomography and transmission electron tomography in order to comparatively analyse the structure and morphometric parameters of thousands of normal- and giant mitochondria in four patients diagnosed with non-alcoholic fatty liver disease. In so doing, we reveal functional alterations associated with mitochondrial gigantism and propose a mechanism for their formation based on our ultrastructural findings.
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Affiliation(s)
- Gerald J Shami
- School of Medical Sciences (Discipline of Anatomy and Histology), The University of Sydney, Camperdown, NSW, 2006, Australia.
| | - Delfine Cheng
- School of Medical Sciences (Discipline of Anatomy and Histology), The University of Sydney, Camperdown, NSW, 2006, Australia
| | - Pauline Verhaegh
- Department of Internal Medicine Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ger Koek
- Department of Internal Medicine Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Eddie Wisse
- Maastricht MultiModal Molecular Imaging Institute, Division of Nanoscopy, Maastricht University, Maastricht, The Netherlands
| | - Filip Braet
- School of Medical Sciences (Discipline of Anatomy and Histology), The University of Sydney, Camperdown, NSW, 2006, Australia
- Sydney Microscopy & Microanalysis, The University of Sydney, Camperdown, NSW, 2006, Australia
- Cellular Imaging Facility, Charles Perkins Centre, The University of Sydney, Camperdown, NSW, 2006, Australia
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Wirtz TH, Buendgens L, Weiskirchen R, Loosen SH, Haehnsen N, Puengel T, Abu Jhaisha S, Brozat JF, Hohlstein P, Koek G, Eisert A, Mohr R, Roderburg C, Luedde T, Trautwein C, Tacke F, Koch A. Association of Serum Calprotectin Concentrations with Mortality in Critically Ill and Septic Patients. Diagnostics (Basel) 2020; 10:E990. [PMID: 33238644 PMCID: PMC7700375 DOI: 10.3390/diagnostics10110990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Calprotectin is present in the cytosol of neutrophil granulocytes and released upon activation. Fecal calprotectin is applied in the clinical management of inflammatory bowel disease whereas serum calprotectin has been discussed as a biomarker in inflammatory disorders. However, its long-term prognostic relevance in critical illness remains unclear. Our aim was to investigate serum calprotectin concentrations as a prognostic biomarker in critically ill and septic patients. Methods: Serum calprotectin concentrations were analyzed in 165 critically ill patients (108 with sepsis, 57 without sepsis) included in our observational study. Patients were enrolled upon admission to the medical intensive care unit (ICU) of the RWTH Aachen University Hospital. Calprotectin concentrations were compared to 24 healthy controls and correlated with clinical parameters, therapeutic interventions, and survival. Results: Serum calprotectin concentrations were significantly increased in ICU patients as well as in septic patients compared to respective controls (p < 0.001 for ICU patients and p = 0.001 for septic patients). Lower calprotectin concentrations were measured in patients with comorbidities i.e., coronary artery disease. Calprotectin concentrations strongly correlated with the C-reactive protein (p < 0.001) and were closely associated to parameters of mechanical ventilation (i.a. inspiratory oxygen fraction, FiO2; p < 0.001). The overall survival was significantly impaired in septic patients with high baseline calprotectin concentrations (p = 0.036). However, patients with increasing calprotectin serum concentrations within the first week of ICU admission showed an improved overall survival (p = 0.009). Conclusions: In summary, serum calprotectin concentrations are significantly increased in critically ill patients with sepsis. High calprotectin concentrations at ICU admission predict long-term mortality risk, whereas increasing calprotectin concentrations are associated with a favorable long-term outcome.
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Affiliation(s)
- Theresa H. Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Lukas Buendgens
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (S.H.L.); (T.L.)
| | - Nina Haehnsen
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Tobias Puengel
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (T.P.); (R.M.); (C.R.); (F.T.)
| | - Samira Abu Jhaisha
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Jonathan F. Brozat
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Philipp Hohlstein
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Ger Koek
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands;
| | - Albrecht Eisert
- Hospital Pharmacy, RWTH-University Hospital Aachen, 52074 Aachen, Germany;
- Institute of Clinical Pharmacology, RWTH-University Hospital Aachen, 52074 Aachen, Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (T.P.); (R.M.); (C.R.); (F.T.)
| | - Christoph Roderburg
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (T.P.); (R.M.); (C.R.); (F.T.)
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany; (S.H.L.); (T.L.)
| | - Christian Trautwein
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (T.P.); (R.M.); (C.R.); (F.T.)
| | - Alexander Koch
- Department of Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (T.H.W.); (L.B.); (N.H.); (S.A.J.); (J.F.B.); (P.H.); (C.T.)
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Verhaegh P, Wisse E, de Munck T, Greve JW, Verheij J, Riedl R, Duimel H, Masclee A, Jonkers D, Koek G. Electron microscopic observations in perfusion-fixed human non-alcoholic fatty liver disease biopsies. Pathology 2020; 53:220-228. [PMID: 33143903 DOI: 10.1016/j.pathol.2020.07.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a widespread liver disease in Western society, but its multifactorial pathogenesis is not yet fully understood. Ultrastructural analysis of liver sinusoidal endothelial cells (LSECs) in animal models and in vitro studies shows defenestration early in the course of NAFLD, promoting steatosis. LSECs and fenestrae are important in the transport of lipids across the sinusoids. However, human ultrastructural data, especially on LSECs and fenestrae, are scarce. This study aimed to explore the ultrastructural changes in perfusion type fixed liver biopsies of NAFLD patients with and without non-alcoholic steatohepatitis (NASH), with a special focus on LSECs and their fenestration. Liver biopsies from patients with NAFLD were fixed using two perfusion techniques, jet and injection fixation, for needle and wedge biopsies, respectively. Ultrastructural changes were studied using transmission electron microscopy. NASH was diagnosed by bright-field microscopy using the SAF score (steatosis, activity, fibrosis). Thirty-seven patients were included, of which 12 (32.4%) had NASH. Significantly less defenestration was found in NASH compared to noNASH samples (p=0.002). Other features, i.e., giant mitochondria and fenestrae size did not differ between groups. Furthermore, we described new structures, i.e., single cell steatonecrosis and inflammatory fat follicles (IFF) that were observed in both groups. Concluding, defenestration was more common in noNASH compared to NASH in human liver samples. Defenestration was not related to the degree of steatosis or fibrosis. We speculate that defenestration can be a protective mechanism in simple steatosis which is lacking in NASH.
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Affiliation(s)
- Pauline Verhaegh
- Department of Internal Medicine, Division Gastroenterology-Hepatology, Maastricht University Medical Center, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands.
| | - Eddie Wisse
- Division of Nanoscopy, Maastricht Multimodal Molecular Imaging Institute, and Department of Internal Medicine/Hepatology, The University of Maastricht, Maastricht, the Netherlands
| | - Toon de Munck
- Department of Internal Medicine, Division Gastroenterology-Hepatology, Maastricht University Medical Center, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Jan Willem Greve
- Department of Surgery, Zuyderland MC, Heerlen, the Netherlands; Department of Gastro-Intestinal Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Joanne Verheij
- Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Robert Riedl
- Department of Pathology, Zuyderland MC, Heerlen, the Netherlands
| | - Hans Duimel
- Division of Nanoscopy, Maastricht Multimodal Molecular Imaging Institute, and Department of Internal Medicine/Hepatology, The University of Maastricht, Maastricht, the Netherlands
| | - Ad Masclee
- Department of Internal Medicine, Division Gastroenterology-Hepatology, Maastricht University Medical Center, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Daisy Jonkers
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Ger Koek
- Department of Internal Medicine, Division Gastroenterology-Hepatology, Maastricht University Medical Center, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Visceral and Transplantation Surgery, Klinikum RWTH, Aachen, Germany
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10
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Czigany Z, Kramp W, Bednarsch J, van der Kroft G, Boecker J, Strnad P, Zimmermann M, Koek G, Neumann UP, Lurje G. Myosteatosis to predict inferior perioperative outcome in patients undergoing orthotopic liver transplantation. Am J Transplant 2020; 20:493-503. [PMID: 31448486 DOI: 10.1111/ajt.15577] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 01/25/2023]
Abstract
Muscle wasting and alterations of body composition are linked to clinical outcomes in numerous medical conditions. The role of myosteatosis in posttransplant outcomes remains to be determined. Here we investigated skeletal muscle mass and myosteatosis as prognostic factors in patients undergoing orthotopic liver transplantation (OLT). The data of 225 consecutive OLT recipients from a prospective database were retrospectively analyzed (May 2010-December 2017). Computed tomography-based skeletal-muscle-index (muscle mass), visceral-fat-area (visceral adiposity), and mean skeletal-muscle-radiation-attenuation (myosteatosis) were calculated using a segmentation tool. Cut-off values of myosteatosis resulted in a good stratification of patients into low- and high-risk groups in terms of morbidity (Clavien-Dindo ≥3b). Patients with myosteatosis had significantly higher complication rates (90-day Comprehensive Complication Index 68 ± 32 vs 44 ± 30, P < .001) and also displayed significantly longer intensive care (18 ± 25 vs 11 ± 21 days, P < .001) and hospital stay (56 ± 55 vs 33 ± 24 days, P < .001). Estimated costs were 44% higher compared to patients without myosteatosis. Multivariable analysis identified myosteatosis as an independent prognostic factor for major morbidity (odds ratio: 2.772, confidence interval: 1.516-5.066, P = .001). Adding myosteatosis to the well-established Balance-of-Risk-(BAR) score resulted in an increased prognostic value compared to the original BAR score. Myosteatosis may be a useful parameter to predict perioperative outcome in patients undergoing OLT, supporting the role of muscle quality (myosteatosis) over quantity (muscle mass) in this setting.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Wiebke Kramp
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Gregory van der Kroft
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Zimmermann
- Institute of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ger Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.,Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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11
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Abstract
Hyperferritinemia, observed in inflammation, iron overload as well as in combination of both, is found in ∼30% of nonalcoholic fatty liver disease (NAFLD) patients. The authors summarized the evidence regarding the potential cause of hyperferritinemia in NAFLD, as this may affect the indicated therapy. A systematic literature search was conducted in EMBASE, PubMed, MEDLINE, and the Cochrane library. In the majority of NAFLD patients, hyperferritinemia is due to inflammation without hepatic iron overload. In a smaller group, a dysmetabolic iron overload syndrome (DIOS) is found, showing hyperferritinemia in combination with mild iron accumulation in the reticuloendothelial cells. The smallest group consists of NAFLD patients with hemochromatosis. Phlebotomy is only effective with hepatocellular iron overload and should not be the treatment when hyperferritinemia is related to inflammation, whether or not combined with DIOS. Treatment with lifestyle changes is to date probably the more effective way until new medication is becoming available.
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Affiliation(s)
- Wenke Moris
- Department of Internal Medicine Gastroenterology and Clinical Geriatrics, Zuyderland Medical Center, Heerlen, The Netherlands.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM) University Maastricht, Maastricht, The Netherlands
| | - Pauline Verhaegh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM) University Maastricht, Maastricht, The Netherlands
| | - Daisy Jonkers
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM) University Maastricht, Maastricht, The Netherlands
| | - Cees van Deursen
- Department of Internal Medicine Gastroenterology and Clinical Geriatrics, Zuyderland Medical Center, Heerlen, The Netherlands.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ger Koek
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM) University Maastricht, Maastricht, The Netherlands.,Department of visceral and transplantation Surgery, Klinikum, RWTH, Aachen, Germany
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12
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Heerkens M, Dedden S, Scheepers H, Van Paassen P, Masclee A, de Die‐Smulders C, Olde Damink SW, Schaap FG, Jansen P, Koek G, Beuers U, Verbeek J. Effect of Plasmapheresis on Cholestatic Pruritus and Autotaxin Activity During Pregnancy. Hepatology 2019; 69:2707-2710. [PMID: 30614557 PMCID: PMC6593664 DOI: 10.1002/hep.30496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/11/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Marieke Heerkens
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Suzanne Dedden
- Department of GynaecologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Hubertina Scheepers
- Department of GynaecologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Pieter Van Paassen
- Department of Internal Medicine, Section of Nephrology and ImmunologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Ad Masclee
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMaastricht University Medical CenterMaastrichtthe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
| | - Christine de Die‐Smulders
- Department of Clinical GeneticsMaastricht University Medical CenterMaastrichtthe Netherlands
- GROW–School for Oncology and Developmental BiologyMaastricht UniversityMaastrichtthe Netherlands
| | - Steven W.M. Olde Damink
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands
- Department of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
| | - Frank G. Schaap
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
- Department of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
| | - Peter Jansen
- Department of SurgeryMaastricht University Medical CenterMaastrichtthe Netherlands
| | - Ger Koek
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMaastricht University Medical CenterMaastrichtthe Netherlands
- NUTRIM School of Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtthe Netherlands
- Department of General, Visceral and Transplantation SurgeryRWTH University Hospital AachenAachenGermany
| | - Ulrich Beuers
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and HepatologyAmsterdam University Medical Centers, location AMCAmsterdamthe Netherlands
| | - Jef Verbeek
- Division of Gastroenterology and Hepatology, Department of Internal MedicineMaastricht University Medical CenterMaastrichtthe Netherlands
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13
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Ehrhart F, Roozen S, Verbeek J, Koek G, Kok G, van Kranen H, Evelo CT, Curfs LMG. Review and gap analysis: molecular pathways leading to fetal alcohol spectrum disorders. Mol Psychiatry 2019; 24:10-17. [PMID: 29892052 PMCID: PMC6325721 DOI: 10.1038/s41380-018-0095-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/17/2017] [Accepted: 04/23/2018] [Indexed: 12/30/2022]
Abstract
Alcohol exposure during pregnancy affects the development of the fetus in various ways and may lead to Fetal Alcohol Spectrum Disorders (FASD). FASD is one of the leading preventable forms of neurodevelopmental disorders. In the light of prevention and early intervention, knowledge on how ethanol exposure induces fetal damage is urgently needed. Besides direct ethanol and acetaldehyde toxicity, alcohol increases oxidative stress, and subsequent general effects (e.g., epigenetic imprinting, gene expression, and metabolite levels). The current review provides an overview of the existing knowledge about specific downstream pathways for FASD that affects e.g., the SHH pathway, cholesterol homeostasis, neurotransmitter signaling, and effects on the cytoskeleton. Available human data vary greatly, while animal studies with controlled ethanol exposition are only to a certain limit transferable to humans. The main deficits in knowledge about FASD are the lack of pathophysiological understanding and dose-response relationships, together with the lack of reliable biomarkers for either FASD detection or estimation of susceptibility. In addition to single outcome experiments, omics data should be generated to overcome this problem. Therefore, for future studies we recommend holistic data driven analysis, which allows integrative analyses over multiple levels of genetic variation, transcriptomics and metabolomics data to investigate the whole image of FASD development and to provide insight in potential drug targets for intervention.
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Affiliation(s)
- Friederike Ehrhart
- Governor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands. .,Department of Bioinformatics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
| | - Sylvia Roozen
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Jef Verbeek
- 0000 0004 0480 1382grid.412966.eDepartment of Internal Medicine, Division of gastroenterology and hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ger Koek
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0004 0480 1382grid.412966.eDepartment of Internal Medicine, Division of gastroenterology and hepatology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Gerjo Kok
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Henk van Kranen
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Institute for Public Health Genomics, Maastricht University, Maastricht, The Netherlands
| | - Chris T. Evelo
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0001 0481 6099grid.5012.6Department of Bioinformatics, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Leopold M. G. Curfs
- 0000 0004 0480 1382grid.412966.eGovernor Kremers Centre, Maastricht University Medical Centre+, Maastricht, The Netherlands ,0000 0004 0480 1382grid.412966.eDepartment of Genetics, Maastricht University Medical Centre+, Maastricht, The Netherlands
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14
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Roozen S, Peters GJY, Kok G, Townend D, Nijhuis J, Koek G, Curfs L. Systematic literature review on which maternal alcohol behaviours are related to fetal alcohol spectrum disorders (FASD). BMJ Open 2018; 8:e022578. [PMID: 30573481 PMCID: PMC6303602 DOI: 10.1136/bmjopen-2018-022578] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Fetal alcohol spectrum disorders (FASD) is a worldwide problem. Maternal alcohol consumption is an important risk factor for FASD. It remains unknown which alcohol consumption patterns most strongly predict FASD. The objective of this study was to identify these. DESIGN Systematic literature review. METHODS We searched in PubMed, PsychINFO, PsycARTICLES, ERIC, CINAHL, Embase and MEDLINE up to August 2018. The query consisted of keywords and their synonyms related to FASD, pregnancy and behaviour. Studies were excluded when not published in English, were reviews or involved non-human subjects. Substantial heterogeneity precluded aggregation or meta-analysis of the data. Instead, data were qualitatively inspected. RESULTS In total, 21 studies were eligible for further data analysis. All studies that measured both maternal alcohol drinking behaviours and FASD reported retrospective data on maternal drinking patterns, employing both continuous and categorical measures and exhibiting substantial heterogeneity in measures of alcohol consumption (eg, timing of exposure, quantification of alcohol measure and definition of a standard drink). Study quality improved over time and appeared higher for studies based on active case ascertainment, especially when conducted in schools and when behaviour was assessed through interviews. CONCLUSIONS We aimed to identify specific maternal drinking behaviour(s) related to FASD. The state of the literature precludes such conclusions. Evidence-based preventive measures necessitate identifying which prenatal alcohol drinking behaviour(s) are most in need of intervention. Therefore, we formulate three recommendations for future research. First, future studies can optimise the value of the collected dataset through specifying measurements and reporting of maternal drinking behaviours and avoiding categorised measures (nominal or ordinal) whenever possible. Second, samples should not be selected based on FASD status, but instead, FASD status as well as maternal alcohol consumption should both be measured in a general population sample. Finally, we provide 10 reporting guidelines for FASD research.
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Affiliation(s)
- Sylvia Roozen
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Gjalt-Jorn Ygram Peters
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
- Faculty of Psychology and Education Science, Open University of The Netherlands, Heerlen, The Netherlands
| | - Gerjo Kok
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - David Townend
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Health, Ethics & Society, Maastricht University, Maastricht, The Netherlands
| | - Jan Nijhuis
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Obstretrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ger Koek
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Leopold Curfs
- Governor Kremers Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
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15
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Verhaegh P, Bavalia R, Winkens B, Masclee A, Jonkers D, Koek G. Noninvasive Tests Do Not Accurately Differentiate Nonalcoholic Steatohepatitis From Simple Steatosis: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:837-861. [PMID: 28838784 DOI: 10.1016/j.cgh.2017.08.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 08/15/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nonalcoholic fatty liver disease is a rapidly increasing health problem. Liver biopsy analysis is the most sensitive test to differentiate between nonalcoholic steatohepatitis (NASH) and simple steatosis (SS), but noninvasive methods are needed. We performed a systematic review and meta-analysis of noninvasive tests for differentiating NASH from SS, focusing on blood markers. METHODS We performed a systematic search of the PubMed, Medline and Embase (1990-2016) databases using defined keywords, limited to full-text papers in English and human adults, and identified 2608 articles. Two independent reviewers screened the articles and identified 122 eligible articles that used liver biopsy as reference standard. If at least 2 studies were available, pooled sensitivity (sensp) and specificity (specp) values were determined using the Meta-Analysis Package for R (metafor). RESULTS In the 122 studies analyzed, 219 different blood markers (107 single markers and 112 scoring systems) were identified to differentiate NASH from simple steatosis, and 22 other diagnostic tests were studied. Markers identified related to several pathophysiological mechanisms. The markers analyzed in the largest proportions of studies were alanine aminotransferase (sensp, 63.5% and specp, 74.4%) within routine biochemical tests, adiponectin (sensp, 72.0% and specp, 75.7%) within inflammatory markers, CK18-M30 (sensp, 68.4% and specp, 74.2%) within markers of cell death or proliferation and homeostatic model assessment of insulin resistance (sensp, 69.0% and specp, 72.7%) within the metabolic markers. Two scoring systems could also be pooled: the NASH test (differentiated NASH from borderline NASH plus simple steatosis with 22.9% sensp and 95.3% specp) and the GlycoNASH test (67.1% sensp and 63.8% specp). CONCLUSION In the meta-analysis, we found no test to differentiate NASH from SS with a high level of pooled sensitivity and specificity (≥80%). However, some blood markers, when included in scoring systems in single studies, identified patients with NASH with ≥80% sensitivity and specificity. Replication studies and more standardized study designs are urgently needed. At present, no marker or scoring system can be recommended for use in clinical practice to differentiate NASH from simple steatosis.
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Affiliation(s)
- Pauline Verhaegh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Roisin Bavalia
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistic, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Ad Masclee
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Daisy Jonkers
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Ger Koek
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, Maastricht University Medical Centre, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands.
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16
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Vanclooster A, van Deursen C, Jaspers R, Cassiman D, Koek G. Proton Pump Inhibitors Decrease Phlebotomy Need in HFE Hemochromatosis: Double-Blind Randomized Placebo-Controlled Trial. Gastroenterology 2017. [PMID: 28624580 DOI: 10.1053/j.gastro.2017.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Phlebotomy constitutes the established treatment for HFE-related hemochromatosis. Retrospective studies have suggested proton pump inhibitors (PPIs) reduce the need for phlebotomy in this population. We conducted a randomized controlled trial to prove this. Thirty p.C282Y homozygous patients were randomly allocated to PPI (pantoprazole 40 mg/day) or placebo for 12 months. Phlebotomies were performed when serum ferritin was > 100 μg/L. Phlebotomy need turned out to be significantly lower in patients taking PPI (P = .0052). PPI treatment significantly reduces the need for phlebotomies in p.C282Y homozygous patients. In view of the known long-term safety profile of PPI, they can be a valuable addition to standard therapy. Clinicaltrials.gov: NCT01524757.
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Affiliation(s)
- Annick Vanclooster
- Department of Gastroenterology-Hepatology and Metabolic Center, University Hospital Leuven, Belgium
| | - Cees van Deursen
- Department of Internal Medicine, Gastroenterology and Clinical Geriatrics, Zuyderland Medical Center, Heerlen, The Netherlands; Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht UMC+, The Netherlands
| | - Reggy Jaspers
- Department of Gastroenterology, Laurentius Hospital Roermond, Roermond, The Netherlands
| | - David Cassiman
- Department of Gastroenterology-Hepatology and Metabolic Center, University Hospital Leuven, Belgium
| | - Ger Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht UMC+, The Netherlands; Nutrition and Translational Research in Metabolism (NUTRIM), University Maastricht, The Netherlands; Department of Surgery, University Hospital of the RWTH, Aachen, Germany.
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17
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van Asten M, Verhaegh P, Koek G, Verbeek J. The increasing burden of NAFLD fibrosis in the general population: Time to bridge the gap between hepatologists and primary care. Hepatology 2017; 65:1078. [PMID: 27862126 DOI: 10.1002/hep.28940] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Marloes van Asten
- Division of Gastroenterology and Hepatology Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Pauline Verhaegh
- Division of Gastroenterology and Hepatology Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ger Koek
- Division of Gastroenterology and Hepatology Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Jef Verbeek
- Division of Gastroenterology and Hepatology Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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18
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Kleinegris MC, Bos MHA, Roest M, Henskens Y, Ten Cate-Hoek A, Van Deursen C, Spronk HMH, Reitsma PH, De Groot PG, Ten Cate H, Koek G. Cirrhosis patients have a coagulopathy that is associated with decreased clot formation capacity. J Thromb Haemost 2014; 12:1647-57. [PMID: 25142532 DOI: 10.1111/jth.12706] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/24/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The coagulopathy in cirrhosis is associated with thrombosis and bleeding. OBJECTIVES To gain better insights into the coagulopathy in patients with cirrhosis, we evaluated plasma thrombin generation and whole blood clot formation in a cross-sectional study. METHODS Blood was collected from 73 patients with all-cause cirrhosis (Child-Pugh-A n = 52, B n = 15, C n = 6) and 20 healthy controls. Activity of the coagulation pathways was measured with assays for factor (F) VIIa and FIXa-antithrombin and FXa-antithrombin complexes, respectively. Thrombin generation by calibrated automated thrombography was determined in platelet-poor plasma using a 1 or 5 pm tissue factor trigger with/without thrombomodulin. ROTEM measurements were performed in whole blood triggered with 35 pm tissue factor without/with 175 ng mL(-1) tissue plasminogen activator (the latter refered to as 'tPA-ROTEM'). RESULTS We observed an increased generation of FVIIa and a moderately elevated amount of FIXa (in complex with antithrombin) without apparent increase in FX activation in patients with cirrhosis. In accordance with this prothrombotic state, markers of thrombin generation potential were also increased upon increasing severity of cirrhosis. In the whole blood clotting assay we observed delayed clot formation and decreased clot strength associated with increased severity of cirrhosis. No significant differences were found for tPA-ROTEM parameters of clot degradation. CONCLUSION These results indicate that cirrhosis patients have an overall procoagulant plasma milieu but a decreased whole blood clot formation capacity with an apparently unaltered resistance to clot lysis.
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Affiliation(s)
- M-C Kleinegris
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
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Vreuls C, Wisse E, Duimel H, Stevens K, Verheyen F, Braet F, Driessen A, Koek G. Jet-fixation: a novel method to improve microscopy of human liver needle biopsies. Hepatology 2014; 59:737-9. [PMID: 23729406 DOI: 10.1002/hep.26532] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/03/2013] [Accepted: 05/10/2013] [Indexed: 12/17/2022]
Affiliation(s)
- Celien Vreuls
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Toebosch S, Tudyka V, Masclee A, Koek G. Treatment of recurrent sigmoid volvulus in Parkinson's disease by percutaneous endoscopic colostomy. World J Gastroenterol 2012; 18:5812-5. [PMID: 23155325 PMCID: PMC3484353 DOI: 10.3748/wjg.v18.i40.5812] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 06/13/2012] [Accepted: 06/28/2012] [Indexed: 02/06/2023] Open
Abstract
The exact aetiology of sigmoid volvulus in Parkinson's disease (PD) remains unclear. A multiplicity of factors may give rise to decreased gastrointestinal function in PD patients. Early recognition and treatment of constipation in PD patients may alter complications like sigmoid volvulus. Treatment of sigmoid volvulus in PD patients does not differ from other patients and involves endoscopic detorsion. If feasible, secondary sigmoidal resection should be performed. However, if the expected surgical morbidity and mortality is unacceptably high or if the patient refuses surgery, percutaneous endoscopic colostomy (PEC) should be considered. We describe an elderly PD patient who presented with sigmoid volvulus. She was treated conservatively with endoscopic detorsion. Surgery was consistently refused by the patient. After recurrence of the sigmoid volvulus a PEC was placed.
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Rombout-Sestrienkova E, van Noord P, Reuser E, Heeremans J, Koek G, Essers B. 41 Therapeutic erythrocytapheresis versus phlebotomy in the treatment of hemochromatosis patients. Results of the cost analysis from a randomised, feasibility and proof of principle trial. Transfus Apher Sci 2010. [DOI: 10.1016/s1473-0502(10)70018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wisse E, Braet F, Duimel H, Vreuls C, Koek G, Olde Damink SWM, van den Broek MAJ, De Geest B, Dejong CHC, Tateno C, Frederik P. Fixation methods for electron microscopy of human and other liver. World J Gastroenterol 2010; 16:2851-66. [PMID: 20556830 PMCID: PMC2887580 DOI: 10.3748/wjg.v16.i23.2851] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
For an electron microscopic study of the liver, expertise and complicated, time-consuming processing of hepatic tissues and cells is needed. The interpretation of electron microscopy (EM) images requires knowledge of the liver fine structure and experience with the numerous artifacts in fixation, embedding, sectioning, contrast staining and microscopic imaging. Hence, the aim of this paper is to present a detailed summary of different methods for the preparation of hepatic cells and tissue, for the purpose of preserving long-standing expertise and to encourage new investigators and clinicians to include EM studies of liver cells and tissue in their projects.
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De Ridder R, Schoon E, Koek G. The effect of bariatric surgery on liver histology. Dig Dis Sci 2007; 52:3532. [PMID: 17417729 PMCID: PMC2071957 DOI: 10.1007/s10620-006-9369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 03/28/2006] [Indexed: 12/09/2022]
Affiliation(s)
- Rogier De Ridder
- Department of Gastroenterology and Hepatology, University Hospital Maastricht, P.O. Box 5800, Maastrict, 6221VA the Netherlands
| | - Erik Schoon
- Department of Gastroenterology and Hepatology, University Hospital Maastricht, P.O. Box 5800, Maastrict, 6221VA the Netherlands
| | - Ger Koek
- Department of Gastroenterology and Hepatology, University Hospital Maastricht, P.O. Box 5800, Maastrict, 6221VA the Netherlands
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Wichers MC, Kenis G, Leue C, Koek G, Robaeys G, Maes M. Baseline immune activation as a risk factor for the onset of depression during interferon-alpha treatment. Biol Psychiatry 2006; 60:77-9. [PMID: 16487941 DOI: 10.1016/j.biopsych.2005.11.024] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2005] [Revised: 10/14/2005] [Accepted: 11/02/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND Major depression has been associated cross-sectionally with increased cell-mediated immune activation but causality has been difficult to establish. This study prospectively investigated the hypothesis that baseline level of immune activation predicts the development of depression during interferon-alpha (IFN-alpha) treatment. METHODS Sixteen hepatitis C patients without psychiatric disorder underwent IFN-alpha treatment. Proinflammatory and anti-inflammatory cytokines were determined before starting treatment. Presence of a major depressive disorder (MDD) was assessed at baseline and several times during treatment. RESULTS Baseline soluble interleukin-2 receptor (sIL-2r), interleukin-6 (IL-6), and interleukin-10 (IL-10) concentrations were significantly increased in the five subjects that developed MDD during treatment compared with those that did not, with standardized effect sizes of 1.08, 1.16, and 1.25, respectively, controlling for marijuana use, cigarette smoking, and baseline level of depressive symptoms. CONCLUSIONS Results suggest that increased immune activation, rather than an epiphenomenon, is a causal risk factor for the development of MDD.
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Affiliation(s)
- Marieke C Wichers
- Department of Psychiatry and Neuropsychology, South Limburg Mental Health Research and Teaching Network, EURON, Maastricht University, Maastricht, The Netherlands.
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Tack J, Koek G, Demedts I, Sifrim D, Janssens J. Gastroesophageal reflux disease poorly responsive to single-dose proton pump inhibitors in patients without Barrett's esophagus: acid reflux, bile reflux, or both? Am J Gastroenterol 2004; 99:981-8. [PMID: 15180713 DOI: 10.1111/j.1572-0241.2004.04171.x] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Studies using ambulatory pH and esophageal bile reflux monitoring (Bilitec) have shown that both acid reflux and duodeno-gastro-esophageal reflux (DGER) frequently occur in patients with gastroesophageal reflux disease (GERD). A subset of patients with GERD has persistent reflux symptoms in spite of standard doses of proton pump inhibitors (PPIs). The aim of the present study was to investigate the role of acid and DGER in patients with reflux disease poorly responsive to PPIs. METHODS Sixty-five patients (32 men, 44 +/- 2 yr) without Barrett's esophagus and with persistent heartburn or regurgitation during standard PPI doses were studied. They underwent upper gastrointestinal endoscopy and simultaneous 24-h ambulatory pH and Bilitec monitoring while PPIs were continued. RESULTS Thirty-three patients (51%) had persistent esophagitis. Seven patients (11%) had only pathological acid exposure, 25 (38%) had only pathological DGER exposure, and 17 (26%) had pathological exposure to both acid and DGER. Acid exposure under PPI was positive in only 37%, but adding Bilitec increased the diagnoses of persistent reflux to 75%. Patients with persistent esophagitis had similar acid exposure, but significantly higher DGER exposure than those without esophagitis. The highest prevalence of esophagitis was found in patients with pathological exposure to both acid and DGER; symptoms did not differ according to the type of reflux. CONCLUSIONS Combined pH and Bilitec monitoring is superior to pH monitoring alone in demonstrating ongoing pathological reflux in patients with medically poorly responsive reflux disease.
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Affiliation(s)
- J Tack
- Center for Gastroenterological Research, Catholic University Leuven, B-3000 Leuven, Belgium
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Abstract
Some methodological in vitro observations concerning bile reflux monitoring (Bilitec) suggested that Bilitec monitoring is underestimating reflux in an acid environment. Moreover, other studies showed that the area above the cutoff level of bilirubin absorbance would provide an adequate quantitative marker for reflux of duodenal contents. Our aim was to study whether correction for intraesophageal acidity and the area above cutoff during Bilitec monitoring affects the results and the correlation with pH measurement and esophageal lesions. In 84 patients (46 men; mean age 46 +/- 2.7 years) evaluated for suspected gastroesophageal reflux disease, we performed ambulatory 24-hr esophageal pH and Bilitec monitoring after an upper gastrointestinal endoscopy. We obtained total area, percent total time, and correction by computer software. The correction factor for bilirubin absorbance was based on literature data for acidified bile (0.06 for pH < 3.6; 0.21 for pH < 2.6). Endoscopy revealed esophagitis grade 1-2 (E1-2) and 3-4 (E3-4) in 23 and 16 patients, respectively. A progressive increase of mixed (acid + bile) reflux occurred with increasing severity of endoscopic lesions (E3-4 vs no esophagitis, P < 0.05). A pathologic Bilitec monitoring result was present in the same 35 patients before and after correction and the correlation between the pH measurement and percent time of bile reflux was not improved by correction for intraesophageal pH (r = 0.386 and r = 0.391; P < 0.05). The total area of bilirubin absorbance above 0.14 (abs x min) was 7.8 +/- 2.2 in patients without esophagitis, and 11.7 +/- 4.4 and 17.0 +/- 4.2 in the E1-2 and E3-4 groups, respectively (E3-4 vs no esophagitis, P < 0.05). The correlation between the Bilitec monitoring and pH measurement regarding percent (r = 0.427, P < 0.01) or area of time below 4 (r = 0.280, P < 0.05) was not improved by considering the area of bilirubin absorbance above the cutoff level. Correction for intraesophageal pH has only a minor effect on the results of ambulatory Bilitec monitoring. Taking into account the surface rather than the percent of time above the cutoff level for bilirubin absorbance does not improve the correlation of Bilitec with acid reflux and with esophageal lesions.
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Affiliation(s)
- R Cuomo
- Department of Internal Medicine, University Hospital Gasthuisberg, University of Leuven, Belgium
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