Epigenetic editing of the Dlg4/PSD95 gene improves cognition in aged and Alzheimer's disease mice

The Dlg4 gene encodes for post-synaptic density protein 95 (PSD95), a major synaptic protein that clusters glutamate receptors and is critical for plasticity. PSD95 levels are diminished in ageing and neurodegenerative disorders, including Alzheimer's disease and Huntington's disease. The epigenetic mechanisms that (dys)regulate transcription of Dlg4/PSD95, or other plasticity genes, are largely unknown, limiting the development of targeted epigenome therapy. We analysed the Dlg4/PSD95 epigenetic landscape in hippocampal tissue and designed a Dlg4/PSD95 gene-targeting strategy: a Dlg4/PSD95 zinc finger DNA-binding domain was engineered and fused to effector domains to either repress (G9a, Suvdel76, SKD) or activate (VP64) transcription, generating artificial transcription factors or epigenetic editors (methylating H3K9). These epi-editors altered critical histone marks and subsequently Dlg4/PSD95 expression, which, importantly, impacted several hippocampal neuron plasticity processes. Intriguingly, transduction of the artificial transcription factor PSD95-VP64 rescued memory deficits in aged and Alzheimer's disease mice. Conclusively, this work validates PSD95 as a key player in memory and establishes epigenetic editing as a potential therapy to treat human neurological disorders.

[Keratin fragments as a serological indicator in patients with a liver disease]

INTRODUCTION

Determination of M30 antigen appears to be a sensitive method for evaluation of hepatocyte apoptosis. The aim of the present project was to implement this technique, compare M30 values in patients with a liver disease and healthy controls and to identify potential relationships between M30 values and other parameters.

METHODS

M30 antigen was assessed in 25 patients with a liver disease and 30 healthy controls. These results were compared between patients with a liver disease and the controls and correlated to a range of clinical and laboratory values, including tissue polypeptide-specific antigen (TPS), in patients with a liver disease.

RESULTS

We found significant differences in M30 values between controls and patients with a liver disease. The only significant correlations were the correlation between M30 and ALT, highly significant correlation between M30 and AST and highly significant correlation between M30 and TPS.

CONCLUSION

The M30 antigen is a sensitive indicator of liver damage. Considering the highly significant correlation with TPS, it can be assumed that in some liver diseases, TPS could serve as a clinically useful indicator of apoptosis.

[Autoimmune pancreatitis and IgG-positive sclerosing cholangitis]

Sclerosing cholangitis is a heterogenous disease. Sclerosing cholangitis with an unknown cause is abbreviated PSC. PSC affects extra- as well as intra-hepatic bile ducts and since this is a permanently progressing fibrous condition, it leads to liver cirrhosis. The disease is often associated with a development of cholangocarcinoma and idiopathic intestinal inflammation. Causal therapy does not exist; liver transplantation is indicated. IgG4 cholangitis differs from PSC in a number of features. This form is, unlike PSC, linked to autoimmune pancreatitis (AIP) as well as other IgG4 sclerosing diseases. Anatomically, distal region of ductus choledochus is most frequently involved. Icterus is, unlike in PSC, a frequent symptom of AIP. There also is a distinctive histological picture--significant lymphoplasmatic infiltration of the bile duct wall with abundance of IgG4 has been described, lymphoplasmatic infiltration with fibrosis in the periportal area and the presence of obliterating phlebitis is also typical. However, intact biliary epithelium is a typical feature. IgG4 can be diagnosed even without concurrent presence of AIP. IgG4 sclerosing cholangitis is a condition sensitive to steroid therapy. At present, there is no doubt that IgG4 sclerosing cholangitis is a completely different condition to primary sclerosing cholangitis. From the clinical perspective, these diseases should be differentiated in every clinician's mind as (a) AIP is treated with corticosteroids and not with an unnecessary surgery, (b) IgG4 sclerosing cholangitis is mostly successfully treated with corticosteroids and the disease is not, unlike PSC, a risk factor for the development of cholangiocarcinoma.

Autoimmune pancreatitis--recent advances

Autoimmune pancreatitis (AIP) is recognized as a distinct clinical entity, identified as a chronic inflammatory process of the pancreas in which the autoimmune mechanism is involved. Clinically and histologically, AIP has two subsets: type 1--lymphoplasmatic sclerosing pancreatitis with abundant infiltration of the pancreas and other affected organs with immunoglobulin G4-positive plasma cells, and type 2--duct centric fibrosis, characterized by granulocyte epithelial lesions in the pancreas without systemic involvement. In the diagnosis of AIP, two diagnostic criterions are used--the HISORt criteria and Asian Diagnostic Criteria. In the differential diagnosis, the pancreatic cancer must be excluded by endosonographically guided pancreatic biopsy. Typical signs of AIP are concomitant disorders in other organs (kidney, liver, biliary tract, salivary glands, colon, retroperitoneum, prostate). Novel clinicopathological entity was proposed as an 'IgG4-related sclerosing disease' (IgG4-RSC). Extensive IgG4-positive plasma cells and T lymphocyte infiltration is a common characteristics of this disease. Recently, IgG4-RSC syndrome was extended to a new entity, characterized by IgG4 hypergammaglobulinemia and IgG4-positive plasma cell infiltration, this being considered an expression of a lymphoproliferative disease, 'IgG4-positive multiorgan lymphoproliferative syndrome'. This syndrome includes Mikulicz's disease, mediastinal fibrosis, autoimmune hypophysitis, and inflammatory pseudotumor--lung, liver, breast. In the therapy of AIP, steroids constitute first-choice treatment. High response to the corticosteroid therapy is an important diagnostic criterion. In the literature, there are no case-control studies that determine if AIP predisposes to pancreatic cancer. Undoubtedly, AIP is currently a hot topic in pancreatology.

[Prophylactic antibiotics and probiotics in acute pancreatitis]

Severe acute pancreatitis is serious disease. High mortality is also due to infection complications. If we will be able to prevent the infection, it could diminish mortality. The role of prevention of infection with antibiotics and probiotics is discussed in the paper.

[Probiotics in acute pancreatitis--a randomised, placebo-controlled, double-blind study]

INTRODUCTION

Infections accompanying pancreatitis, particularly pancreatic necroses, represent a serious complication associated with worsening of the disease prognosis. The aim of our study was to explore whether this complication could be prevented by administering a probiotic.

METHODS

The probiotic was administered to 7 patients and placebo to 15. The study was discontinued early following the release of the Propatria study results.

RESULTS

There was no death in our patient sample and there was no difference between the two groups in microbial colonisation or the length of hospitalization. However, a reduction in endotoxin levels on day 7 and 10 of the hospitalization was observed in the probiotic-treated group.

CONCLUSION

Based on the current knowledge, administration of probiotics in this indication is contraindicated. Nonetheless, reduction in endotoxin levels suggests a positive effect of probiotics on bacterial translocation, the importance of which should be evaluated in the future.

[Liver cirrhosis and its treatment]

Cirrhosis is an end-stage liver disease. It is necessary to always search for the cause, attempt to initiate suitable causal treatment and assess the severity of hepatopathy by evaluating hepatic functional reserve (according to the Child-Pugh classification). It is necessary to continually monitor possible complications of cirrhosis, some can be prevented. Regular clinical and laboratory monitoring as well as ultrasound and endoscopic examinations are required. The paper discusses the treatment of the disease as well as its complications. Cure can only be achieved with a liver transplant; this option should be evaluated by a hepatologist in each patient with functional classification B or with serious complications of portal hypertension mentioned above. Treatment standards compiled by the Czech Society of Hepatology (http://www.ceska-hepatologie.cz) offer the basic algorithms of correct diagnosis and treatment.

[Bacterial infection and its relation to the genesis and course of varicose hemorrhage]

Acute hemorrhage from esophageal varices due to portal hypertension is a frequent and serious complication of liver cirrhosis. Bacterial infection may be one of the factors influencing such hemorrhage. Endotoxins may increase portal tension and at the same time result in primary hemostasis disorder, thus becoming one of the causes of hemorrhage. The authors of the paper compared the incidence of bacterial infection in 53 patients with varicose hemorrhage due to portal hypertension with 62 patients with liver cirrhosis and portal hypertension without varicose hemorrhage. At least one pathogen was found in considerable 61.1% of the total of patients in the liver cirrhosis group, while the difference between the two groups was but insignificant. No statistically significant difference was found between the group of patients with hemorrhage and those without hemorrhage in terms of presence of bacterial infection in hemoculture, urine, throat, faeces and ascites, nor was there a difference in the etiology of the G+ bacteria, G- bacteria or fungi and yeast infectious agents in the hemoculture, urine, throat, faeces and ascites in either of the groups. No statistically significant difference was found in comparing the patients with a recurrence of hemorrhage (or with mortality) and with infection with those without recurrence of hemorrhage. Bacterial infection was more often found in patients with a recurrence of hemorrhage (75%) as compared with those without any recurrence (52%), and also in patients who died bacterial infection was proven more often than in those who survived (61.9% vs. 58.1%, respectively). There was no difference in morbidity or recurrence of hemorrhage between the patients treated with norfloxacin and ampicilin/sulbactam. No statistically significant difference was recorded between the 1st and 5th day in terms of decrease in bacterial infection. A significant difference was found in the urine etiological agent, where a significant increase in the share of fungal and yeast urine infection (p = 0.011) was recorded after the application of the therapy, as well as a drop in urine infection caused by the G- bacterial agent (p = 0.057).

[Diagnostics and therapy of hepatorenal syndrome. Recommendations of of the working group on portal hypertension of the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]

Hepatorenal syndrome is a functional renal failure in patients with advanced cirrhosis and portal hypertension or acute liver failure. It is caused by extreme vasoconstriction in renal arterial bed. Type I HRS presents as an acute renal failure, while type II HRS is chronic alteration of renal function in patients with refractory ascites. Prognosis of HRS is very poor with survival reaching several weeks in patients with HRS type I. Causal treatment is liver transplantation, other treatment options include use of splanchnic vasoconstrictors (terlipressin) together with plasmaexpansion (albumin) and TIPS. It is important to exclude nephrotoxic medication (non-steroid anti inflammatory drugs, aminoglycosides) and properly treat all infective complications in prevention of HRS.

[Effect of administration of Escherichia coli Nissle (Mutaflor) on intestinal colonisation, endo-toxemia, liver function and minimal hepatic encephalopathy in patients with liver cirrhosis]

The purpose of the study was to verify effects of Escherichia coli Nissle (Mutaflor) on intestinal colonisation, endotoxin levels, hepatic encephalopathy and liver function in patients with liver cirrhosis. The study involved 39 patients (22 taking Mutaflor and 17 taking placebo). Even though the number combination test showed extended reaction time in patients with described minimal hepatic encephalopathy the drop was not significant in the trend evaluation. However, the treated group displayed significant improvement of intestinal colonisation (p < 0.001) and a trend towards significant reduction of endotoxin levels on day 42 (p = 0.07) and improvement of liver function assessed with the Child-Pugh classification on days 42 and 84 (p = 0.06). Probiotic preparations can therefore represent a significant contribution to this group therapy.

[The diagnostics and therapy of hepatic encephalopathy. Recommendations of of the working group on portal hypertension in the Czech Hepatology Society and the J. E. Purkinje Czech Medical Society]

Hepatic encephalopathy (HE) is a set of reversible neuropsychic features which occur in connection with hepatic cirrhosis or acute hepatic failure. We distinguish manifest HE (with clinical symptoms) and minimal FE (normal clinical finding, abnormal psychometric or neurophysiologic exam). The diagnosis is clinical or laboratory one. From the auxiliary examinations in common practice the number connection test is sufficient.

THERAPY

Presence of hepatic encephalopathy should lead to the consideration of the possibility to solve basic disease by hepatic transplantation. Conservative therapy lies in 1. Basic disease elimination, 2. Measures lowering the ammonia level in blood--optimalization of protein intake, administration of indigestible disaccharides (lactulose, lactitol) and fill sterilisation by antibiotics (Rifaxin, Metronidazol), ornitine-aspartate administration, 3. Influencing the changes in amino acid metabolism (administration of branched chain amino acids--BCAA). Prognosis depends on the advancement of the disease, after hepatic transplantation the clinical symptoms of HE are mostly fully reversible.

Evaluation of labeling and content of probiotics available in the Czech Republic

Probiotics are live cultures of mikroorganisms which are good for human health and are used in human medicine as a treatment. Advantageous effect on a human health was proved in many studies in Europe and in the USA. On the other hand, many studies described lack of information about products containing probiotics - in particular the real bacterial strain or quantity of bacteria. We tried to evaluate thirteen products containing probiotics available in the Czech Republic. In all cases the leaflets contained information about the species and amount of bacteria (from seven products containing more than one species of bacteria were only in two cases declared the quantity of particular bacteria, in five cases was declared just the total quantity of bacteria). The declared species of bacteria were cultured in all tested products. Concluding; the information on the leaflets of probiotic products is sufficient for a clinical practice and the real species and quantity of bacteria come up to declared data.

[Diagnostics and treatment of hepatocellular carcinoma. Recommendations of the Portal Hypertension Working Group of the Czech Hepatology Society and the J.E. Purkinje Czech Medical Society ]

Hepatocellular carcionma (HCC) is almost exclusively associated with liver cirrhosis as a significant HCC risk marker in advanced countries. Applicable therapy depends on early diagnosis, and risk patients should be screened for the presence of HCC on a regular basis. Liver ultrasound and determination of alpha-fetoprotein serum levels (AFP) are the screening methods used. Spiral CT is the most often used method for HCC staging. Non-invasive methods may under certain circumstances replace aimed biopsy. There are 3 basic curative therapies for the early stage of HCC: liver transplantation, surgical resection and different methods of local destruction of tumour (i.e., ethanolisation, thermoablation, etc.). Patients at medium stage of HCC may profit from chemoembolisation. Current available systemic chemotherapy is ineffective. Patients with advanced HCC are treated symptomatically. Patient survival prognosis after the application of one of the above treatment methods may be similar with that for HCC free cirrhosis patients, however, prognosis for advanced HCC patients is bad, with survival period from one to nine months.

Bacterial infection and acute bleeding from upper gastrointestinal tract in patients with liver cirrhosis

BACKGROUND/AIMS

Acute bleeding from the upper gastrointestinal tract is a common and serious complication of liver cirrhosis. It is believed that bacterial infection may be the immediate cause of the bleeding and the latest meta-analyses show that bacterial infection is an independent predictive factor of the failure to stop bleeding.

METHODOLOGY

The authors evaluated the presence of bacterial infection (blood, urine, throat and ascitic fluid) in 35 consecutive patients with liver cirrhosis and acute bleeding with portal hypertension and compared these results with a group of 35 patients with liver cirrhosis with portal hypertension without acute bleeding.

RESULTS

According to the results obtained, there is a statistically higher incidence of bacterial infection among patients with acute bleeding with portal hypertension (25 of 35 patients, 71%) than among patients with liver cirrhosis and portal hypertension without acute bleeding (14 of 35 patients, 40%, p < 0.01). The incidence of bacteriological findings in blood and throat samples is statistically higher in patients with acute bleeding as opposed to the control group (p < 0.05).

CONCLUSIONS

These results confirm the necessity of administering antibiotic prophylaxis to all cirrhotic patients with variceal bleeding, not just to those with confirmed infection or symptoms thereof.

[Factors participating in development of bleeding varices in portal hypertension. Part II: Possible impact of kidney damage and malnutrition, mortality]

An acute bleeding from oesophageal varices as a result of portal hypertension is a frequent and serious complication of liver cirrhosis. The development of oesophageal varices and their rupture depends on the portal pressure. However, a range of other factors can contribute to a development of bleeding and its negative prognosis. A sample of 46 patients admitted for the acute bleeding has been compared to 48 cirrhosis patients hospitalised for other conditions in this work. There were significantly higher levels of nitrogenous matters in bleeding patients (urea 14.1 mmol/l vs. 7.78 mmol/l, p < 0.01, creatinine 129.8 micromol/l vs. 106.04 micromol/l, p = 0.09). Perhaps it can't be said that impaired renal functions alone increase the risk of bleeding. From this point of view they could rather be seen as definite prognostic markers of the degree of portal hypertension. Moreover, there was a decreased level of total proteins in bleeding patients (60.7 g/l vs. 69.9 g/l, p < 0.01) at a mild nonsignificant decrease of albumin (26.64 g/l vs. 28.51 g/l). Cirrhotic patients are known to suffer from malnutrition and there is a possibility that malnutrition can contribute to development of bleeding. A prognostic marker of mortality was a considerable impairment of liver function (bilirubin 97.4 micromol/l vs. 57.4 micromol/l; p = 0.1 and prolonged prothrombin time 1.99 INR vs. 1.56 INR; p = 0.09) and impaired kidney function (creatinine 166.7 micromol/l vs. 114.9 micromol/l, p = 0.09). Therefore a care of a good renal function must be a part of the complex care of bleeding patients.

[Factors participating in development of bleeding varices in portal hypertension. Part I: bacterial infection and comparison of intravenous and peroral antibiotics effects--a randomised study]

An acute bleeding from oesophageal varices as a result of portal hypertension is a frequent and at the same time serious complication of cirrhosis of the liver. One of factors influencing this bleeding can be a bacterial infection. Endotoxines can increase portal pressure and so participate in development of bleeding and simultaneously deteriorate a patient's prognosis. An antibiotic treatment is a part of a treatment algorithm, however what antibiotics to administer and in what manner is unclear. A group of 46 patients who were admitted to a hospital for an acute bleeding from varices has been compared in the study to 48 cirrhosis patients hospitalised for other reasons. An infection incidence was high in both groups (63.0 % vs. 54.2 %), bleeding patients had more often positive hemoculture (17.3 % vs. 8.6 %), and statistically significantly more often positive findings in throat swab culture (36.9 % vs. 17.3 %, p = 0.04) which is an evidence of an increased pathology colonisation of these patients. Bleeding patients were randomised for peroral norfloxacin administration (n = 25) or an intravenous administration of a combination of ampicilin and sulbactam (n = 21). There was no difference in survival of both groups. Due to a high number of bacterial infections antibiotics administration has been indicated in these patients. Intravenous administration is probably of the same effect as peroral administration.

[Large-droplet liver steatosis in celiac disease]

Authors monitored a case of a 25 years old woman who was admitted for swelling of lower limbs. Laboratory results showed hypoproteinemia, elevation of liver enzymes, and prolonged prothrombin time. Ultrasound examination proved hepatomegalia with diffusely hyperechogenic liver without central lesion. Computer tomography confirmed hepatomegalia with diffusely hyperechogenic liver and a suspicion of liver steatosis was expressed. Liver biopsy confirmed serious diffuse large droplet steatosis of unclear genesis. Carried out examinations excluded infectious and autoimmune liver diseases, metabolic diseases, and congenital liver diseases (Wilson's disease, porphyria, haemochromatosis etc.). Laboratory results showed gliadin, endomysin, and reticulin antibodies. An enteroscopy picture showed villi decrease. Histology examination of a biopsy specimen confirmed total villi atrophy with non-differentiated enterocytes and round-cell cellulisation of epithelium and proprium. Histology and histochemical findings were distinct proves of coeliac disease. A patient was prescribed a gluten free diet. Her metabolic parameters (normalisation of albumine levels, prothrombine time, and trace elements) and anino transferase levels gradually improved. This case documents development of a serious liver disorder as a result of malnutrition which developed in a young woman as a result of unrecognised coeliac disease.

[Procalcitonin as an indicator of infection in patients with liver cirrhosis]

Incidence of bacterial infections in hospitalised patients with liver disease is high. Due to a liver dysfunction immune reactivity is significantly impaired and bacterial infections are more frequent. Also incidence of nosocomial infections is higher in patients with liver disease compared to patients hospitalised for other conditions. To make a differential diagnosis of infectious and non-infectious aetiology of an inflammation is very difficult. Characteristic laboratory tests for bacterial infection include test of a number of leucocytes in peripheral blood, differential count of leucocytes, erythrocyte sedimentation, procalcitonin, C-reactive protein, tumor necrosis factor alpha, interleukin-1, interleukin-6, interleukin-8, and complement fragment C3a. Clinically the most significant are C-reactive protein test and procalcitonin test. Procalcitonin is a protein, a calcitonin precursor, which is in healthy individuals produced by cells of thyroid gland. A half-life of procalcitonin in serum is 20-24 hours which makes it suitable for daily monitoring and enables to control a course of treatment and to distinguish bacterial infection from other types of inflammations. Procalcitonin levels rise in bacterial, parasite, and yeast infections. Elevated procalcitonin levels appear only in inflammations of an infectious etiology with systemic signs. In patients with liver cirrhosis bacterial infections are more frequent. They usually include spontaneous bacterial peritonitis, infection of the respiratory system, urinary infections, and bacteremia. A timely proof of a bacterial infection and an appropriate and effective antibiotic therapy lead to an improvement of the general state of a patient and to his/her better prognosis. Procalcitonin determination is appropriate for diagnosing infections and control of treatment.

[Antibiotic prophylaxis in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute bleeding from upper part of gastrointestinal tract is a frequent and serious complication affecting 20 to 60% of patients with liver cirrhosis and portal hypertension. It is associated with a high death rate of 30 to 50% and a frequent relapse of bleeding occurs in up to 40% of these patients. The most recent meta-analyses have shown that bacterial infection is an independent factor in the failure of blood hemostasis and significantly influenced mortality in these patients. The authors investigated 25 patients with acute bleeding from the upper part of gastrointestinal tract due to portal hypertension in patients with liver cirrhosis. Irrespective of the proved bacterial infection the patients were given antibiotic prophylaxis. In 13 patients the authors administered norfloxacin orally and 12 patients were treated intravenously with ampicilin/sulbactam. The prophylaxis of the bleeding cirrhotic patients by norfloxacin (orally) resulted in a statistically significant prevention of early relapse as compared with the therapy by ampicilin/sulbactam (intravenously). The death rate reached 40% in spite of the antibiotic prophylaxis. There was no significant difference in the death rate between the two groups with different treatments.

Unusual Bochdalek hernia in puerperium

The authors present an unusual case of a true left-sided posterolateral (Bochdalek) hernia containing stomach, transverse colon and spleen within a hernial sac in a 25-year-old female patient. They presume this voluminous herniation took place due to a rupture of congenitally preformed hernial ostium on account of increased intraabdominal pressure during repeated pregnancy. They describe an effective surgical transabdominal laparoscopic treatment.

[Drug therapy of portal hypertension]

The author presents a list of preparations used to influence portal hypertension resulting from cirrhosis of the liver, in particular in treatment or prevention of haemorrhage from oesophageal varices or gastropathy. The author describes the mechanism of action of drugs administered in acute haemorrhage (vasopressin, terlipressin, somatostatin, octreotide)) and preparations used in primary or secondary prevention of this haemorrhage (beta-blockers, nitrates, newly tested preparations or combinations). In the conclusion are recommendations for practical procedures according to principles of evidence-based medicine.

[Bacterial infections in patients with acute hemorrhage due to portal hypertension--personal experience]

Acute haemorrhage from the upper gastrointestinal tract is a frequent and serious complication which affects 20-60% patients with cirrhosis of the liver and portal hypertension. It is assumed that bacterial infections can be the direct cause of haemorrhage but accurate data on the influence of infection on the development and course of haemorrhage are lacking. Acute haemorrhage as a result of portal hypertension has a very high mortality, 30-50%, and an early relapse of haemorrhage occurs in as many as 40% of these patients. Most recent meta-analyses indicate that bacterial infection is an independent prognostic factor in failure of haemostasis and has a significant impact on the mortality of these patients. The authors examined for the presence of bacterial infection (blood, urine, throat, ascites) 25 patients with cirrhosis of the liver and acute haemorrhage as a result of portal hypertension and compared the results with a group of 25 patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. According to the results in patients with acute haemorrhage due to portal hypertension there is a significantly higher incidence of bacterial infections than in patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. The results confirm the necessity to administer antibiotic prophylaxis to cirrhotic patients with varicose bleeding, not only to patients with symptoms and evidence of infection but also in their absence. Antibiotic prophylaxis extends the survival period of these patients.

[Influence of bacterial infection on the development and course of acute haemorrhage from oesophageal varices]

Acute haemorrhage from the upper portion of the gastrointestinal tract is a frequent complication which develops in ca 35-66 % of patients with cirrhosis of the liver and portal hypertension. It is assumed that one of the trigger mechanisms of varicose haemorrhage can be bacterial infection. However accurate data on the influence of infection on the development and course of haemorrhage are still lacking. The mortality of patients bleeding from oesophageal varices is very high (30-70%). Usually the cause of death is not haemorrhagic shock but haemorrhage-induced changes which lead to hepatic failure. It is assumed that in this very process an important part is played by bacterial infection with subsequent release of endotoxins. Most recent metaanalyses indicate that bacterial infection is an independent prognostic factor as regards failure to arrest haemorrhage and influences in a significant way the mortality of these patients. Antibiotic treatment of patients with varicose haemorrhage increases the survival period of these patients. Therefore to cirrhotic patients with varicose haemorrhage antibiotics should be administered prophylactically, i.e. not only to patients with evidence of infection but also those without these symptoms. The authors consider as the optimal antibiotic treatment administration of quinolones orally or by the i.v. route, possibly cephalosporins which seem to be equally effective as quinolones.

Double-blind randomized, comparative multicenter study of the effect of terlipressin in the treatment of acute esophageal variceal and/or hypertensive gastropathy bleeding

BACKGROUND/AIMS

1) To compare the effect of 2-day application of 0.2 mg terlipressin i.v. every 4 hours (group I) with that of 5-day application of 1 mg i.v. every 4 hours (group II) in the treatment of bleeding esophageal varices and portal gastropathy. 2) To assess the incidence of adverse events.

METHODOLOGY

Eighty-six patients with liver cirrhosis (54 men and 32 women, average age 51 years) were randomized over a period of 2 years into 2 groups. Acute bleeding was diagnosed endoscopically within 24 hours of its onset. The two groups fully comparable; treatment failure rated according to "Baveno II".

RESULTS

Success rate in group I was 78% at day 2 and 75% at day 5; in group II 89% and 79%, respectively (no statistical significance). Rebleeding had occurred by day 5 in 15% in group I, and in 16.3% in group II. Transfusion needs by day 2 were significantly lower in group II (2.4 units compare to 3.4 units in I). The 30-day mortality was 17.1% in group I and 20% in group II. No statistical difference between I and II in the occurrence of adverse events.

CONCLUSIONS

At a dosage of 1 mg i.v. every 4 hours, the success rate at day 2 was as much as 90% while blood consumption was significantly lower compared with the lower dosage. Rebleeding during first 48 hours occurred almost exclusively at lower dosage. There was no increase in the rate of adverse events relative to the higher dosage.

[Rifaximin in the treatment of hepatic encephalopathy]

Hepatic encephalopathy is a frequent and serious complication of liver cirrhosis. Usually it is treated by non-absorbable disaccharides or antibiotics and its treatment is often difficult and associated with undesirable effects. The objective of our investigation was to evaluate the safety and effectiveness of a new antibiotic used in this indication--rifaximine. With rifaximine, 400 mg three times per day, a total of 25 patients were treated for a 10-day period. Significant improvement of the manifestations of encephalopathy occurred (evaluated by the grade of encephalopathy, test of combining numerals, the degree of flapping tremor and the arterial ammonia level). None of the patients developed undesirable effects. Rifaximine seems an effective, safe drug for hepatic encephalopathy.

[Spontaneous bacterial peritonitis in the Czech Republic]

The objective of the study was to assess the prevalence and more detailed data pertaining to the incidence of spontaneous bacterial peritonitis (SBP) in the Czech Republic. The authors examined 99 patients with cirrhosis of the liver and ascites. SBP was diagnosed in a high percentage--35 patients, i.e. 35.4%. It was found more frequently in patients with an alcoholic etiology of cirrhosis who had a history of subfebrile and febrile temperatures and increasing trend of ascites. For the diagnosis the increase of leucocytes in serum and C reactive protein levels may prove useful. Lower values of total protein and albumin in ascites predispose to the development of this infection. Reduction of the number of thrombocytes in the group of patients with SBP indicates the influence of portal hypertension in the etiology of this disease.

[Chronic pancreatitis in endoscopic ultrasonography--analysis of newly diagnosed cases during a 28-month period]

Endoscopic ultrasonography (EUS) is an imaging method visualising the entire pancreas by use of high-frequency ultrasound probes introduced into the close proximity of the pancreas. During the 38-month period, our clinic has examined 148 patients with the diagnostic conclusion of chronic pancreatitis. This diagnosis was newly assessed in 72 of them. Approximately one third of cases with chronic pancreatitis were in their early stages. Despite this fact, in 22% of them, the first manifestation of chronic pancreatitis was represented by biliary duct stenosis while in 15% of cases the stenosis was not caused by the presence of any focal process, but by diffuse inflammatory changes. This proportion is unusually high in comparison with literature data. (Tab. 5, Ref. 22.)

Cytotoxicity of natural compounds in hepatocyte cell culture models. The case of quaternary benzo[c]phenanthridine alkaloids

The quaternary benzo[c]phenanthridine alkaloids (QBA) produce a plethora of species- and tissue-specific effects but the molecular basis of their biological activities remain mysterious. The objective of the present study was to investigate the cytotoxicity of QBA alkaloids, sanguinarine (SA), chelerythrine (CHE), fagaronine (FA), and the extract from Macleaya cordata in primary cultures of human and porcine hepatocytes. The cellular damage was assessed by the MTT assay, lactate dehydrogenase (LDH) leakage and the determination of intracellular glutathione (GSH) levels. The results are summarised as follows: (i) The alkaloids tested in doses 0.1 and 10 microM did not display statistically significant cytotoxicity for 0-3 h incubation; (ii) SA and CHE showed the dose- and time-dependent toxicity within the range 25-100 microM whereas FA was not toxic; (iii) the LDH leakage into the medium was higher for SA than for CHE, thus revealing a potent potential of SA to disturb cell-membrane integrity; (iv) after 3 h incubation with 100 microM SA/CHE, mitochondrial dehydrogenase activity (MTT assay) and the cellular GSH levels decreased to residual values of about 40% suggesting that mitochondria are unlikely to be a primary target for SA/CHE in the cell; (v) no differences were found in the response to QBA application in human vs porcine hepatocyte.

[Transplantation of hepatocytes--present status and future perspectives]

Transplantation of hepatocytes as an alternative to the transplantation of the liver has been investigated since the 70s of the 20th century. Work on animal models confirmed that transplanted hepatocytes can survive, reproduce and compensate for missing liver functions, Recent clinical studies indicate that hepatocyte transplantation can also play its part in the treatment of acute liver failure, some inborn metabolic deficiencies and liver cirrhosis. In the acute liver failure, metabolic support by means of hepatocytes can help to overcome the period up to transplantation or regeneration of the liver. In the case of loss of a major fraction of the liver cells, transplanted hepatocytes may colonize the liver. the isolation of hepatocytes and procedure of transplantation proper are under control and the work focusing on the improvement of cell preservation is under way. Hepatocyte gene manipulation proves to be promising. The shortage of donors and the necessity of long-term immunosuppression represent the greatest problem. The article analyzes the basic principles of hepatocyte transplantation, the contemporary state of clinical application and further perspectives of research.

[Protective effect of essential phospholipids on liver injury due to total parenteral nutrition]

OBJECTIVE

It is known that total parenteral nutrition (TPN) causes liver damage by various mechanisms and leads to an increase of transaminases and obstructional enzymes. From this aspect TPN can be considered an external factor which causes liver damage. In our investigation we wanted to find out whether parenteral administration of essential phospholipids (EPL) can have a protective effect on this damage.

PATIENTS AND METHODS

Our investigation comprised 20 patients where TPN was indicated, usually on account of severe acute exacerbation of a non-specific inflammation of the gut. The patients were divided into two groups. Ten patients were treated by intravenous administration of essential phospholipids (Essentiale, Aventis), 50 mg every 6 hours for a period of two weeks. The control group comprised ten patients without hepatoprotection. The bilirubin, ALT, AST, GMT, ALP values were assessed before the initiation of the study, on the seventh and fourteenth day. The results were statistically processed by the paired and non-paired t-test.

RESULTS

The baseline results of the mentioned tests did not differ significantly between groups. Bilirubin and AST did not change significantly during the investigation. In the control group we found, as compared with baseline values, a significantly increase of ALT on the seventh and fourteenth day, a significantly increase of GMT on the seventh and fourteenth day and a slight non-significant rise of ALP on the fourteenth day. In the ELP treated group, as compared with baseline values, a significant rise of ALT occurred on the fourteenth day. We did not observe a significant rise of GMT and ALP. Between the ELP treated and control group a significant increase of GMT and ALP occurred in the control group, the other values did not differ between groups.

CONCLUSION

Parenteral EPL administration can have a favourable effect on liver damage caused by TPN, associated with cholestasis and biliary sludge. This conclusion can be hypothetically explained by improved bile fluidity and protection of the bile pole of the hepatocyte by essential phospholipids. Therefore their administration during TPN can be recommended.

Incidence of chronic pancreatitis in the Czech Republic

There have been only a few studies dealing with the incidence of chronic pancreatitis published. Over the last 80 years, original studies describing the incidence of chronic pancreatitis were undertaken, including studies in Scandinavia, Switzerland, Hungary and Poland. Incidence varied geographically, from 1.6 new cases per year among 100,000 inhabitants in Switzerland to 23 new cases among 100,000 inhabitants in Finland. The aetiology of 70% of all cases was alcoholic pancreatitis. The incidence of chronic pancreatitis in the Czech Republic is 7.9 per 100,000 inhabitants per year, similar to that of Denmark and Germany, but higher than that of Poland or Switzerland. In our study, the main aetiological factor was alcohol (65.4% of all cases, with consumption of alcohol of > 75.0 g/day).

[Acute hemorrhage of the upper digestive tract--personal experience]

The authors submit a retrospective investigation of 50 patients hospitalized at the intensive care unit of the Medical gastroenterological department, Faculty Hospital Brno treated in 1999 with the diagnosis of acute haemorrhage into the upper digestive tract. In the investigated group the most frequent cause of haemorrhage was portal hypertension (21 patients, 32.8%) and a peptic gastroduodenal lesion (15 patients, 23.4%). During the investigation period 12 patients died (18.8%), 6 developed haemorrhage as a complication of a serious condition (decompensated cirrhosis of the liver). In haemorrhage from oesophageal and gastric varicosities pharmacotherapy is equally important as endoscopic intervention.

[Uncommon case of a giant diaphragmatic hernia in a pregnant patient]

The authors submit an uncommon case of a true leftsided posterolateral (Bochdalek) hernia with the stomach, transverse colon and spleen in the hernial sac in a 25-year-old patient. They assume that the large hernation developed as a result of rupture of an already congenitally preformed hernial opening as a result of intraabdominally increased pressure during repeated pregnancies. The authors describe effective surgical solution of the case by laparoscopy from a transabdominal approach.

[Acute pancreatitis as the road to diagnosis of primary hyperparathyroidism]

The authors present the case of a 78-year-old female patient who was admitted on account of acute pancreatitis complicated by acute myocardial infarction. The authors detected in the patient a serum repeatedly high calcium levels and high levels of intact parathormone. Scintigraphic examination revealed marked foci in the middle of the neck at the level of the inferior pole of the thyroid gland. These examinations confirmed the diagnosis of primary hyperparathyroidism. In view of the patient a serious condition, conservative treatment of hypercalcaemia and acute pancreatitis and myocardial infarction was started. The patient was released into domiciliary care after 40 days in hospital in a state of cardiopulmonary compensation, with cystic transformation of the pancreas and without signs of acute pancreatitis.

[Helicobacter pylori negative gastroduodenal lesions in subjects treated with NSAID]

The authors examined retrospectively the frequency of NSAID use by patients with gastroduodenal ulcer without HP. The objective was to evaluate whether the use of NSAID is the predominating factor in the development of ulceration in subjects with HP negative ulceration. The group comprised 525 patients with confirmed presence of H, incl. 52 who used NSAID. From the results ensues that the incidence of ulcerous lesions with HP negativity and NSAID medication is significantly higher than in subjects who use NSAID and suffer from a confirmed HP infection.

Overgrowth of a costochondral graft in temporomandibular joint reconstructive surgery: an uncommon complication

A 16-year-old girl had a history of unilateral ankylosis of the temporomandibular joint, which was reconstructed with an autogenous costochondral graft. About 2.5 years after surgery, the patient presented with overgrowth of the costochondral graft, resulting in deviation of the jaw toward the unaffected side.

[The bioartificial liver--an alternative in the treatment of acute liver failure]

One of the therapeutic approaches in acute liver failure is the use of an artificial system replacing hepatic function--bioartificial liver. Its application is the most perspective in fulminant liver failure during preparation for transplantation of the liver (so-called bridge to transplantation) or in case of a non-functioning hepatic graft, and to reduce the mortality and morbidity of patients with acute liver failure where transplantation is not indicated or where a suitable graft was not found. The authors discuss briefly the construction of these systems, analyze different indications of treatment and its results, obscure questions and perspectives of further development.

[Principles of conservative treatment in chronic pancreatitis]

The authors summarize the principles of conservative treatment of chronic pancreatitis with special attention to treatment of exocrine pancreatic insufficiency and pancreatic pain. They emphasize the principles of the rational administration of drugs with pancreatin, the position of analgesics, and other possible procedures, if medicamentous treatment fails. An outline of dietetic treatment is also given.

[An attack of malignant hyperthermia caused by a combination of the effects of succinylcholine, increased physical exertion and alcohol abuse]

The authors submit the case-history of a 29-year-old man, followed up on account of liver steatosis with a toxic-nutritional etiology who developed, after previous increased physical exertion and alcohol abuse, fever associated with major muscular weakness. Gradually he developed an amental delirious state which was evaluated as suspect delirium tremens. Fever of 40-41 degrees C continued, the patient developed muscular rigidity, tremor and hypotension. After intubation during which succinylcholine was administered, the patient's condition deteriorated further with a rise of temperature and muscular rigidity. The patient developed acute renal failure with anuria and the necessity of repeated haemodialyses and severe acidosis of the mixed type on account of which he was intubated and switched to artificial ventilation. According to the case-history clinical and laboratory picture of the disease (extremely high creatine kinase activity, hyperkalaemia, acidosis, hepatorenal failure) malignant hyperthermia was suspected. After a single intravenous injection of sodium dantrolene, 2.5 mg/kg, the temperature dropped and within 24 hours the patient was afebrile. Gradually the acidosis improved, the blood pressure became stabilized and artificial ventilation was no longer used. The patient was discharged after 34 days in hospital in a state of cardiopulmonary compensation with mild polyuria but without signs of retention of nitrogenous substances with sideropenic anaemia and marginal creatine kinase and lactate dehydrogenase values. Within one month after discharge the laboratory values reached normal levels and only slight muscular weakness and greater fatiguability persisted.

[Drug therapy of esophageal varices hemorrhage in portal hypertension]

The author discusses the etiopathogenesis of portal hypertension and possibilities how to influence it during treatment of acute haemorrhage from varicosities and how to implement primary and secondary prevention. In treatment of acute haemorrhage the author recommends terlipresin, 1 mg every 4 hours. In primary and in particular in secondary prevention he emphasizes the necessity of early administration of beta-blockers.

Sturge Weber syndrome with intraoral manifestations. A case report

A 15 Year old female patient with Sturge Weber Syndrome is presented. This neurocutaneous syndrome consists of angiomatosis of the skin and mucosa as well as the leptomeninges. This case report describes the classic presentation of the syndrome, emphasizing the oral manifestations. The radiographic and CT scan show the typical "tram line" intracranial calcifications. This case report presents a typical case of Sturge Weber Syndrome. It gives the radiological and CT scan findings and the important role played by them in the diagnosis of this syndrome. Emphasis is given to the differentiation of diphenylhydantoin induced gingival hyperplasia from the angiomatous enlargement of the gingiva before any treatment is planned.

[Effect of octreotide on the clinical course of acute pancreatitis and levels of free oxygen radicals and antioxidants]

Twenty-one patients with a medium severe form of acute pancreatitis were divided into two groups. Eleven were treated with octreotide, 200 micrograms s.c. every 8 hours, combined with standard conservative treatment, 10 patients had the same treatment but without octreotide. In the octreotide-treated group the level of free oxygen radicals and important antioxidants--vitamins A, E and C--was assessed. In the octreotide-treated group the authors found after five days normal levels of originally elevated free oxygen radicals and a significant increase of the vitamin C level. As compared with the control group, in the octreotide group the period of hospitalization was significantly shorter (9.8 +/- 3.2 vs. 13.7 +/- 4.7). The number of complications was not affected.

A rare foreign body impaction: a case report

A case of unusual foreign body impaction of 6 years' duration is reported. The foreign body was retained in the right infraorbital region, extending to the ethmoid sinus. The importance of careful history taking and clinical examination and the problems encountered in evaluation of relatively radiolucent foreign bodies with magnetic resonance imaging are discussed.