A86 CANNABIS USE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IS HIGHER FOLLOWING LEGALIZATION OF CANNABIS IN CANADA AND IS ASSOCIATED WITH LOWER QUALITY OF LIFE

Background

Patients with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), often experience fluctuating and unpredictable symptoms. Most individuals require chronic therapy with immunomodulators or novel biologics to maintain disease remission. In addition to conventional medical therapy, many patients also seek out alternative therapies such as cannabis. Reports in the USA suggest that cannabis is used by ~12% of UC and ~16% of CD patients, despite it being legally prohibited.

Purpose

The aim of our study is to evaluate the use of cannabis in a cohort of patients with IBD following its legalization in Canada, and to assess its effects on IBD disease severity.

Method

We conducted a prospective cohort study of adult IBD patients seen in clinic at a tertiary care center in London, ON. Patients completed an online 40-question survey that collected data on demographics, IBD disease history, cannabis use, and included the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). The survey was distributed and collected by the REDCap platform maintained by Western University. The study was approved by the Western University Ethics Committee.

Result(s)

Completed surveys were obtained from 254 individuals (148 individuals with CD, 90 with UC and 16 with indeterminate colitis). Over half of participants were between 35-64 years of age and female. Fifty-three percent of participants reported life-time cannabis use and 51% of users started using cannabis only in the preceding 3 years. Individuals with CD had higher rates of recent use, defined as use within the past 6 months, when compared with UC (41% vs 31%). Cannabis was taken multiple times per week by 57% of users. Cannabis was used to treat GI symptoms by 30% of users, as well as to help with sleep (26%) and for recreation (27%). Despite side effects such as dry mouth, anxiety and concentration issues, 79% of users felt the benefits of cannabis outweighed its harms. Interestingly, only 46% of cannabis users discussed their use with their family physician or gastroenterologist. Recent cannabis users did not differ in the use of IBD medication or self-reported rates of GI symptoms. Furthermore, recent users did not differ in the rates of surgical procedures for IBD (recent 35% vs non-recent 32%). Recent cannabis users did have a significantly lower quality of life as indicated by SIBDQ scores when compared to non-recent users (recent use 37 vs non-recent use 40).

Conclusion(s)

Cannabis use among patients with IBD after its legalization is more than double the rate previously reported in the literature. Importantly, physicians are likely to be unaware of its prevalence in their practice. Cannabis was used by patients to treat GI and non-GI symptoms, and it was associated with lower SIBDQ scores. Our results suggest that physicians should inquire about Cannabis use amongst their patients with IBD, and that further studies are required to determine its effects on disease severity.

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Severity of coeliac disease and clinical management study when using a non-metabolised medication: a phase I pharmacokinetic study

OBJECTIVE

The non-metabolised antihistamine fexofenadine has oral absorption resulting from transporter activity. Uptake by enterocyte organic anion transporting polypeptides and efflux by an ATP-binding cassette transporter (P-glycoprotein) are primary determinants. Coeliac disease-mediated lesions to the small intestinal mucosa may alter oral absorption of the drug probe, fexofenadine.

DESIGN

A phase I, open-label, single-dose, pharmacokinetic study SETTING: London, Ontario, Canada PARTICIPANTS: Patients with coeliac disease (n=41) with positive serology and healthy individuals (n=48).

MAIN OUTCOME MEASURES

Patients with coeliac disease-duodenal histology and oral fexofenadine pharmacokinetics within a 3-week period. Healthy individuals-oral fexofenadine pharmacokinetics with water and grapefruit juice.

RESULTS

Patients with coeliac disease were stratified by disease severity: Group A (n=15, normal), B+C (n=14, intraepithelial lymphocytosis with/without mild villous blunting) and D (n=12, moderate to severe villous blunting). Patients with coeliac disease in groups A, B+C and D and healthy individuals receiving water had similar fexofenadine AUC0-8 (2038±304, 2259±367, 2128±410, 1954±138 ng.h/mL; p>0.05; mean±SEM) and Cmax (440±73, 513±96, 523±104, 453±32 ng/mL; p>0.05), respectively. These four groups all had higher fexofenadine AUC0-8 (1063±59; p<0.01) and Cmax (253±18; p<0.05) compared with those for healthy individuals receiving grapefruit juice. Coeliac groups had a positive linear trend between disease severity and fexofenadine Tmax (2.0±0.3, 2.7±0.4, 3.1±0.5 hours; p<0.05).

CONCLUSIONS

Coeliac disease severity based on duodenal histopathology did not affect oral fexofenadine bioavailability. Increased Tmax suggested absorption distal to the duodenum (jejunum + ileum), where histology seems more normal which may be the key determinant. Patients with coeliac disease may not require consideration for alternative clinical drug management for a number of non-metabolised and transport-mediated medications.

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics

IMPORTANCE

Trainees routinely participate in colonoscopy procedures, yet whether their involvement is positively or negatively associated with procedural quality is unknown because prior studies involved small number of trainees and/or supervisors, lacked generalizability, and/or failed to adjust for potential confounders.

OBJECTIVE

To assess the association between trainee participation and colonoscopy quality metrics.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter population-based cohort study was conducted at 21 academic and community hospitals between April 1, 2017, and October 31, 2018, among consecutive adult patients undergoing colonoscopy. Procedures performed by endoscopists who did not supervise trainees were excluded. Statistical analysis was performed from April 3, 2017, to October 31, 2018.

EXPOSURE

Participation by a trainee, defined as a resident or fellow enrolled in a gastroenterology or general surgery training program.

MAIN OUTCOMES AND MEASURES

The primary outcome was the adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate.

RESULTS

A total of 35 499 colonoscopies (18 989 women [53.5%]; mean [SD] patient age, 60.0 [14.1] years) were performed by 71 physicians (mean [SD] time in practice, 14.0 [9.3] years); 5941 colonoscopies (16.7%) involved trainees. There were no significant differences in the ADR (26.4% vs 27.3%; P = .19), CIR (96.7% vs 97.2%; P = .07), and perforation rate (0.05% vs 0.06%; P = .82) when trainees participated vs when they did not participate, whereas the the ssPDR (4.4% vs 5.2%; P = .009) and PDR (39.2% vs 42.0%; P < .001) were significantly lower when trainees participated vs when they did not. After adjustment for potential confounders, the ADR (risk ratio [RR], 0.97; 95% CI, 0.91-1.03; P = .30), PDR (RR, 0.98; 95% CI, 0.93-1.04; P = .47), and CIR (RR, 0.93; 95% CI, 0.78-1.10; P = .38) were not associated with trainee participation, although the ssPDR remained significantly lower (RR, 0.79; 95% CI, 0.64-0.98; P = .03).

CONCLUSIONS AND RELEVANCE

This study suggests that trainee involvement during colonoscopy was associated with reduced ssPDR but not other colonoscopy outcome measures. Extra care should be exercised when examining the right colon when trainees are involved.

Clinical, Endoscopic, and Radiological Effectiveness of Ustekinumab in Bio-naïve Versus Bio-experienced Patients With Crohn's Disease: Real-world Experience From a Large Canadian Center

INTRODUCTION

With the expanding therapeutic armamentarium for inflammatory bowel disease (IBD), real-world data may help inform drug positioning. We assessed clinical, endoscopic, imaging, and biochemical response/remission outcomes in patients with Crohn's disease (CD) treated with ustekinumab in a large Canadian IBD center.

METHODS

A retrospective cohort study of CD patients was treated with ustekinumab. Clinical, endoscopic, radiological, and biochemical response and remission outcomes were stratified by prior biologic exposure status. Hazard ratios for biologic exposure status were estimated using Cox proportional hazard models and subgroup-specific incidence rates for healing.

RESULTS

A total of 231 patients (55.9% female, median 45.8 years) were identified as receiving ustekinumab during the study period, with 2 patients subsequently excluded (N = 229). Of these patients, 79.0% (181 of 229) were bio-experienced, with 38.7% (70 of 181) having failed 1 biologic and 61.3% (111 of 181) having failed ≥2 biologics. At 3 months of follow-up after induction, clinical remission (Harvey-Bradshaw Index ≤4) was achieved by 59.1% (62 of 105) of bio-experienced patients and 79.4% (27 of 34) of bio-naïve patients (relative risk [RR], 1.34; 95% CI, 1.06-1.70; P = .013). Endoscopic remission (absence of mucosal ulcers) was achieved in 37.9% (33 of 87) cases. Rate of endoscopic healing (either endoscopic response or remission) per 1000 person-months was 72.7 (95% CI, 42.4-125.1) and 50.2 (37.9-66.4); and the median time to endoscopic response was 8.4 months (95% CI, 6.4-9.8) and 15.4 months (95% CI, 10.3-17.9) in bio-naïve vs bio-experienced patients, respectively. Imaging response/remission and steroid-free remission rates were higher in bio-naïve patients.

CONCLUSION

In this large real-world cohort of CD patients with complex phenotypes and high rates of prior biologic exposure, we observed that ustekinumab was effective and safe with higher rates of improvement in bio-naïve subjects across a range of end points.

High oncostatin M predicts lack of clinical remission for patients with inflammatory bowel disease on tumor necrosis factor α antagonists

The interleukin-6 family cytokine, oncostatin-M (OSM) has been associated with response to tumor necrosis factor-α antagonists (anti-TNFs) in small cohorts of patients with inflammatory bowel disease (IBD). We aimed to evaluate the association between plasma OSM concentrations and response to anti-TNFs (infliximab and adalimumab) in both ulcerative colitis (UC) and Crohn’s disease (CD). A retrospective cohort study was conducted in patients with IBD with a history of anti-TNF exposure. Blood samples, collected prior to anti-TNF exposure, were analyzed by enzyme-linked immunosorbent assay for the presence and quantity of OSM. Clinical remission was assessed at 1-year post anti-TNF exposure in addition to the occurrence of surgery, hospitalization, corticosteroid use, and adverse drug events. Lastly the threshold OSM plasma concentration associated with anti-TNF non-response was assessed by receiver operator characteristic (ROC) curve analysis. Patients with IBD (CD, n = 82; UC, n = 40) were assessed. In both UC and CD, mean pre-treatment OSM concentrations were significantly lower in those who achieved clinical remission at 1-year (p < 0.0001). A threshold plasma OSM concentration of 168.7 pg/ml and 233.6 pg/ml respectively separated those who achieved clinical remission at 1-year on an anti-TNF from those who did not in CD and UC respectively (CD: area under the receiver operator characteristic curve, AUROC = 0.880, 95% CI 0.79–0.96; UC: AUROC = 0.938, 95% CI 0.87–1.00). High OSM concentrations were associated with anti-TNF discontinuation and use of rescue steroids in CD and UC. High pre-treatment OSM concentrations identify IBD patients at-risk of anti-TNF non-response at 1-year as well as other deleterious clinical outcomes.

The Tricky Trachea: Tracheitis and Mediastinitis Treated With Infliximab and Steroids in a Patient With Ulcerative Colitis

Pulmonary extra-intestinal manifestations of inflammatory bowel disease are rare, comprising 0.21% to 0.4% of the inflammatory bowel disease population. Common symptoms include cough, chest pain, and dyspnea. Abnormal pulmonary function tests are common in these patients, with restrictive, obstructive, and diffusion capacity defects. CT scanning remains the most sensitive imaging technique to detect abnormalities. Pulmonary manifestations are diverse and include airway, parenchymal, and pleural disease. Large airway disease predominates, particularly bronchiectasis. Upper airway disease is rare but concerning for the development of acute airway compromise. To our knowledge, there are no reports of concurrent mediastinitis with tracheitis in the setting of inflammatory bowel disease. We present a case of a patient with ulcerative proctitis who experienced the development of inflammatory tracheitis and mediastinitis. Her disease responded to systemic steroids and biologic therapy. In addition to our case, we reviewed the literature and provide an approach to pulmonary complications as extra-intestinal manifestation of inflammatory bowel disease.

Severity of coeliac disease and clinical management study when using a CYP3A4 metabolised medication: a phase I pharmacokinetic study

OBJECTIVE

Severity of coeliac disease depends in part on the extent of small intestinal mucosa injury. Patients with the most abnormal pathology have loss of duodenal villi CYP3A4, a drug-metabolising enzyme that inactivates many drugs. These patients are hypothesised to have greater systemic concentrations of felodipine, a drug which normally has low oral bioavailability secondary to intestinal CYP3A4-mediated metabolism. It serves as a representative for a class containing many medications.

DESIGN

A phase I, open-label, single-dose, pharmacokinetic study.

SETTING

London, Ontario, Canada.

PARTICIPANTS

Patients with coeliac disease (n=47) with positive serology and healthy individuals (n=68).

MAIN OUTCOME MEASURES

Patients with coeliac disease-upper gastrointestinal endoscopy and oral felodipine pharmacokinetics study within a 3-week period. Healthy individuals-oral felodipine pharmacokinetics study with water and grapefruit juice.

RESULTS

Coeliac stratification categories: Group A (n=15, normal), B+C (n=16, intraepithelial lymphocytosis with/without mild villous blunting) and D (n=16, moderate/severe villous blunting). Groups A, B+C and D had linear trends of increasing felodipine AUC_0-8; mean±SEM, 14.4±2.1, 17.6±2.8, 25.7±5.0; p<0.05) and Cmax (3.5±0.5, 4.0±0.6, 6.4±1.1; p<0.02), respectively. Healthy subjects receiving water had lower felodipine AUC_0-8 (11.9±0.9 vs 26.9±0.9, p=0.0001) and Cmax (2.9±0.2 vs 7.7±0.2, p=0.0001) relative to those receiving grapefruit juice.

CONCLUSIONS

Increased felodipine concentrations in patients with coeliac disease were most probably secondary to decreased small intestinal CYP3A4 expression. Patients with severe coeliac disease and healthy individuals with grapefruit juice had equivalently enhanced effect. Thus, patients with severe coeliac disease would probably experience similarly altered drug response, including overdose toxicity, from many important medications known to be metabolised by CYP3A4. Patients with coeliac disease with severe disease should be considered for other clinical drug management, particularly when there is the potential for serious drug toxicity.

Presence of Melena in Obscure Gastrointestinal Bleeding Predicts Bleeding in the Proximal Small Intestine

BACKGROUND AND AIMS

Melena is a symptom of upper gastrointestinal bleeding and usually indicates bleeding proximal to the ligament of Treitz. However, whether melena predicts bleeding in the proximal small intestine in patients with obscure gastrointestinal bleeding (OGIB) is unknown and the objective of this study.

METHODS

A retrospective cohort study of consecutive patients undergoing capsule endoscopy for OGIB between July 2009 and May 2016 was conducted. Subjects were categorized based on the presence of melena, and the primary outcome was identification of a bleeding source within the proximal 2/3 of the small intestine. Multi-variable regression was performed to control for confounders.

RESULTS

During the study, 288 patients met the eligibility criteria. Subjects with melena accounted for 37.1% of the cohort and were more likely to be older (mean age 66.9 vs. 63.9, p = 0.0457), take warfarin (15.1 vs. 9.4%, p = 0.0122), and have a lower 12-month hemoglobin nadir (7.3 vs. 8.3 g/dL, p = 0.0002). On crude analysis, 56.1% of patients with melena had a bleeding source within the proximal small intestine compared to 34.8% for those without (RR 1.61, 95% CI 1.24-2.09, p = 0.0004). On multi-variable analysis, the presence of melena doubled the odds of finding a bleeding site within the proximal small intestine (OR 1.97, 95% CI 1.17-3.33, p = 0.010).

CONCLUSIONS

The presence of melena doubles the odds of finding a bleeding site within the proximal small intestine among patients with OGIB, and deep enteroscopy, if performed before a capsule study, should begin with an antegrade approach in these patients.

Insertion of percutaneous endoscopic gastrostomy tubes with jejunal extensions using the "wedge" technique: a novel method to prevent retrograde tube migration into the stomach

Background and study aim In percutaneous endoscopic gastrostomy (PEG) with jejunal extension (PEGJ) procedures, retrograde migration of the jejunal extension tube into the stomach during endoscope withdrawal is a frustrating problem. We describe the novel "wedge" technique for inserting the jejunal extension tube, utilizing single-balloon enteroscopy to anchor it in place. Patients and methods Prospective 1-year study of consecutive patients undergoing PEGJ insertion at a single tertiary care center. The primary outcome was number of pyloric intubations required to place the jejunal extension tube. Secondary outcomes included success rate, time, and complications related to jejunal extension tube insertion. Results 17 patients underwent the procedure. The jejunal extension tube was inserted at the first attempt in 15 patients (88.2 %) and 2 required another pyloric intubation. Abdominal X-ray showed that all PEGJ tubes were successfully seated in the proximal jejunum. The mean (SD) time required for jejunal extension insertion was 16.9 (8.6) minutes. Two adverse events occurred due to PEG insertion although none were related to the jejunal extension insertion itself. Conclusions: The "wedge" technique is an effective and easy method for inserting a jejunal extension tube after PEG insertion.

The utility of fecal calprotectin in predicting the need for escalation of therapy in inflammatory bowel disease

BACKGROUND AND AIMS

Fecal calprotectin is an important biomarker used in the evaluation of inflammatory bowel disease. It has proven to be an effective tool in initial screening as well monitoring response to therapy. The aim of this study is to examine the utility of fecal calprotectin both as a predictor for the escalation of therapy in established inflammatory bowel disease and as a predictor of de novo diagnosis.

METHODS

Patients with signs and symptoms concerning for inflammatory bowel disease presenting to outpatient clinics were recruited to provide fecal calprotectin stool samples prior to endoscopic evaluation. Patients were followed up for at least one year and monitored clinically for any change in symptomatology, escalation of therapy or development of IBD, confirmed endoscopically.

RESULTS

A total of 126 patients, of whom 72 were known to have underlying inflammatory bowel disease, were included in the final analysis. Among the patients with elevated fecal calprotectin levels and known inflammatory bowel disease, 66% (33/50) went on to have escalation of therapy within 12 months compared to 18% (4/22) if the fecal calprotectin levels were in the normal range (p < .0001). For the remaining patients who at baseline did not have inflammatory bowel disease and a normal endoscopic evaluation, elevated fecal calprotectin resulted in no cases (0/17) of a new diagnosis in the next 12 months.

CONCLUSIONS

Fecal calprotectin is a useful test for predicting escalation of therapy in established inflammatory bowel disease.

The structural basis for calcium inhibition of lipid kinase PI4K IIalpha and comparison with the apo state

PI4K IIalpha is a critical enzyme for the maintenance of Golgi and is also known to function in the synaptic vesicles. The product of its catalytical function, phosphatidylinositol 4-phosphate (PI4P), is an important lipid molecule because it is a hallmark of the Golgi and TGN, is directly recognized by many proteins and also serves as a precursor molecule for synthesis of higher phosphoinositides. Here, we report crystal structures of PI4K IIalpha enzyme in the apo-state and inhibited by calcium. The apo-structure reveals a surprising rigidity of the active site residues important for catalytic activity. The structure of calcium inhibited kinase reveals how calcium locks ATP in the active site.

Self-Screening for Malnutrition Risk in Outpatient Inflammatory Bowel Disease Patients Using the Malnutrition Universal Screening Tool (MUST)

BACKGROUND AND AIMS

Malnutrition is common in patients with inflammatory bowel disease (IBD) and is associated with poor outcomes. Our aim is to determine if patient self-administered malnutrition screening using the malnutrition universal screening tool (MUST) is reliable by comparing patient scores with those derived from the healthcare practitioner (HCP), the gold standard.

METHODS

We conducted a prospective validation study at a tertiary Canadian academic center that included 154 adult outpatients with IBD. All patients with IBD completed a self-administered nutrition screening assessment using the MUST score followed by an independent MUST assessment performed by HCPs. The main outcome measure was chance-corrected agreement (κ) of malnutrition risk categorization.

RESULTS

For patient-administered MUST, the chance-corrected agreement κ (95% confidence interval [CI]) was 0.83 (0.74-0.92) when comparing low-risk and combined medium- and high-risk patients with HCP screening. Weighted κ analysis comparing all 3 risks groups yielded a κ (95% CI) of 0.85 (0.77-0.93) between patient and HCP screening. All patients were able to screen themselves. Overall, 96% of patients reported the MUST questionnaire as either very easy or easy to understand and to complete.

CONCLUSION

Self-administered nutrition screening in outpatients with IBD is valid using the MUST screening tool and is easy to use. If adopted, this tool will increase utilization of malnutrition screening in hectic outpatient clinic settings and will help HCPs determine which patients require additional nutrition support.

[Psychoneuroimmunology in context of comprehensive breast cancer treatment]

BACKGROUND

Numerous studies have proven a relationship between stress and cancer progression or recurrence, and on the other hand, positive effects of psychological and social support and interventions on cancer patients quality of life.

PURPOSE

This review article aims to provide an overview of recent studies that dealt with effects of psychosocial interventions on health and psychological state of breast cancer patients, from cellular and immune response over coping skills to overall survival.

CONCLUSION

Both short- and long-term studies have proven positive effects of psychosocial interventions on levels of stress hormones, cellular (immune) response and general patients quality of life. On the other hand, findings on overall survival are contradictory and cannot provide unambiguous conclusions.

[Objective need for cancer prevention in the Czech Republic and Europe, and the state thereof]

There is no doubt today of the need for cancer prevention. The growing incidence of cancer itself provides a sufficient justification for prevention programmes. A review of literature presented in this paper also documents the strong background of evidence-based cancer prevention programmes. The article also provides a critical analysis of the current status of primary cancer prevention and cancer screening in the Czech Republic in contrast with available international comparisons. Relevant international data have been obtained from the regularly repeated "Health at a Glance" studies (published by the OECD). Although the Czech Republic is one of the countries with the highest cancer burden in Europe, it has failed to develop and support a cancer prevention policy on a central level, and this also applies to smoking prevention. The Czech population needs an effective national strategy for the support of cancer prevention, as well as a strategy which would ensure equitable cancer care in terms of both quality and correct indication; a strategy which would be sustainable for at least 10 to 15 years to come.Key words: oncology - screening - risk factor - prevention - population burden This study was supported by the project 36/14//NAP "Development and implementation of methodology for the evaluation of effectiveness of personalised invitations of citizens to cancer screening programmes" as part of the pro-gram-me of the Czech Ministry of Health "National action plans and conceptions". The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE "uniform requirements" for biomedical papers.

[National web portals as an official communication platform of cancer screening programmes]

Official web portals are an important component of the background information of the cancer screening programmes. They provide up-to-date and relevant information for health care professionals, the general public and those interested in preventive examinations. They also serve as an official medium for publication of individual programme outcomes. The Czech national screening programmes are presented at the following websites: www.mamo.cz (breast cancer screening), www.kolorektum.cz (colorectal cancer screening), and www.cervix.cz (cervical cancer screening).

[Approach to population-based screening in the Czech Republic, methodology and first results of the personalised invitation of citizens to cancer screening programmes]

In January 2014, a programme of personalised invitations was launched in the Czech Republic, with the objective of inviting insured persons to cancer screening programmes; namely breast cancer screening and cervical cancer screening in women, and colorectal cancer screening both in women and men. This programme aims at strengthening the current cancer prevention programmes, and to increase the currently inadequate participation of the target population in these programmes; therefore, personalised invitations are sent to citizens who have not participated in these programmes for several years and therefore at risk of developing a serious disease. The project is coordinated by the Czech Ministry of Health in cooperation with the expert medical societies involved (gynaecology, gastroenterology, gastrointestinal oncology, diagnostic radiology, general practice), representatives of health care payers, and other experts nominated by the Minister of Health. All health care payers invite their clients (insured persons) to preventive check-ups, covering all examinations needed. The project has been realised with the assistance of financial resources from EU funds. This article describes the methodology of personalised invitations which has been implemented nationwide, its data background, and the first results of the project in the first half of 2014, when almost 1.3 million Czech citizens were invited.

[New European Information and Communication Platform Striving for Improved Care for Colorectal Cancer Patients - www.crcprevention.eu]

The article introduces a new information and communication platform that focuses on the promotion of colorectal cancer prevention and on the improvement of care for colorectal cancer patients. In addition to the platforms objectives, the article also presents the conclusions of the first year of the "European Colorectal Cancer Days" international conference held annually in Brno since 2012. Further information and news are available at www.crcprevention.eu.

[Epidemiology of cancers with implemented screening programmes in an international comparison]

International data document that the Czech Republic ranks among the countries with the highest cancer burden in Europe and worldwide. Preventable cancer diseases, i.e. colorectal, breast, and cervical cancer, are among the most frequent types. These international studies also bring some positive information, e.g., stabilised or slightly decreasing mortality, better treatment outcomes and patient survival rates. However, it should be noted that, with regard to the high population burden, these results are achieved at the very high price of costly modern cancer treatment.

[Epidemiology of screening-targeted cancers according to new data of the Czech National Cancer Registry]

The Czech Society for Oncology has developed an information system which combines the population-based Czech National Cancer Registry with clinical databases in order to cover the main areas of health care assessment - monitoring of the population burden, prediction of the number of cancer patients, diagnostic and treatment results. The presented data demonstrate a high cancer burden within the Czech population - each year there are approximately 8,000 new cases of colorectal cancer, 6,500 new cases of breast cancer, and 1,000 new cases of cervical cancer. And each year, about 4,000 people die from colorectal cancer, around 2,000 women die from breast cancer, and approximately 400 women die from cervical cancer in the Czech Republic. Population-based screening programmes focus on all of the above-mentioned groups of malignant tumours; therefore, it is essential to monitor epidemiological trends in order to assess the screening impact. Despite the high incidence rates of all three cancer types, the trend in mortality rates has been stable or has even decreased in the long term, which has inevitably led to a significant increase in the total prevalence of cancer patients. In 2011, the prevalence of colorectal cancer, breast cancer and cervical cancer amounted to 51,064 people, 67,261 women and 17,398 women, respectively. When compared with the year 2001, there was a 59%, 69% and 25% increase in the prevalence of colorectal cancer, breast cancer, and cervical cancer, respectively. Undoubtedly, taking care of high numbers of cancer patients will continue to require significant financial resources in the near future. As the epidemiological burden is still on the increase, preventive programmes need to be further promoted, including secondary prevention, which is provided through organised screening programmes. Although effective methods exist for timely diagnosis of all three of the above-mentioned cancer types, the epidemiological situation in the Czech Republic is being steadily worsened by a relatively high proportion of primary cancers being diagnosed too late. Each year, more than 50% of new colorectal cancer cases are diagnosed in clinical stage III or higher; in cervical cancer, this proportion is nearly 35%. By contrast, the well-promoted breast cancer screening programme has led to more than 75% of new cases of breast cancer being diagnosed in stages I or II, when the chance of successful treatment is significantly higher.

[State and development of background information for the evaluation of Czech cancer screening programmes]

Czech cancer screening programmes feature a comprehensive multimodal information system which covers all the levels of assessment needed - population-based monitoring (Czech National Cancer Registry), monitoring of results in the diagnostic databases of centres, as well as the quantification of coverage and outputs of primary care according to the administrative data of health care payers. A system of personalised invitations to cancer screening programmes was launched in 2014, based on a stand-alone component of the information system which makes it possible to identify eligible clients in health care payers databases. The system was fully standardised and uniformly implemented in all health insurance companies; its functionalities also involve both continuous and retrospective assessment of the results of personalised invitation. The legislative framework in force will have to be applied and implemented for a more comprehensive and integrated employment of all involved data sources, i.e. cancer registries, screening registries, and administrative data. The system must be able to analyse de-identified individual records on clients participation in screening programmes, and thus to ensure an adequate analysis of performance indicators in compliance with international recommendations.

[Role and importance of civil society organisations in the support of cancer screening]

Promotion of cancer screening programmes and provision of correct and comprehensive information to the general public are essential for achieving sufficient attendance at the program-mes and fulfilling their longterm function. Various NGOs and CSOs play a very important role in this field. The article provides an overview of the most visible activities and campaigns that spread information about cancer prevention and preventive examinations in the Czech Republic.

Transcutaneous bowel sonography for inflammatory bowel disease is sensitive and specific when performed in a nonexpert low-volume North American center

OBJECTIVES

Transcutaneous bowel sonography is a nonionizing imaging modality used in inflammatory bowel disease. Although available in Europe, its uptake in North America has been limited. Since the accuracy of bowel sonography is highly operator dependent, low-volume centers in North America may not achieve the same diagnostic accuracy reported in the European literature. Our objective was to determine the diagnostic accuracy of bowel sonography in a nonexpert low-volume center.

METHODS

All cases of bowel sonography at a single tertiary care center during an 18-month period were reviewed. Bowel sonography was compared with reference standards, including small-bowel follow-through, computed tomography, magnetic resonance imaging, colonoscopy, and surgical findings.

RESULTS

A total of 103 cases were included for analysis during the study period. The final diagnoses included Crohn disease (72), ulcerative colitis (8), hemolytic uremic syndrome (1), and normal (22). The sensitivity and specificity of bowel sonography for intestinal wall inflammation were 87.8% and 92.6%, respectively. In the subset of patients who had complications of Crohn disease, the sensitivity and specificity were 50% and 100% for fistulas and 14% and 100% for strictures. One patient had an abscess, which was detected by bowel sonography. Abnormal bowel sonographic findings contributed to the escalation of treatment in 55% of cases.

CONCLUSIONS

Bowel sonography for inflammatory bowel disease can be performed in low-volume centers and provides diagnostic accuracy for luminal disease comparable with published data, although it is less sensitive for complications of Crohn disease.

Retrospective analysis of disease association and outcome in histologically confirmed ischemic colitis

OBJECTIVE

To identify risk factors, clinical features and complications in patients with ischemic colitis (IC).

METHODS

All patients diagnosed with biopsy proven IC within a 2-year period were identified; clinical data were retrospectively collected and subsequently analyzed.

RESULTS

In total, 72 IC patients with a mean age of 68 years were included in this study. Among them, 18 (25.0%) were younger than 65 years with a female predominance. One-third of the patients was found to be without vascular risk factors, and 8 patients met the criteria for irritable bowel syndrome. No history of oral contraceptives or hormonal replacement therapy use could be found among the women diagnosed with IC. Over a mean duration of follow-up of 9.5 months (range 0-65 months), the rate of recurrent disease was 16.7%, while only 2 (2.8%) patients developed extra intestinal vascular sequelae. Statistical analysis identified a history of atrial fibrillation and the use of furosemide to be the only significant predictors of a poor outcome, while coronary artery disease and chronic renal failure predicted recurrence and low platelet count predicted stricture formation.

CONCLUSIONS

Although most patients with IC are elderly and have conventional vascular risk factors, it should also be considered in young patients without vascular risk factors, especially in women, who may have an atypical distribution of the disease. Severe complications and extraintestinal vascular sequelae are rare, however, residual gastrointestinal complaints and recurrent disease are relatively common and there are no reliable predictors of the outcome.

Nonutility of routine testing of stool for ova and parasites in a tertiary care Canadian centre

Background In many clinical situations, stool examinations for ova and parasites (O&P) are routine in the work-up of patients with acute or chronic diarrhea. Frequently, these tests are found to be negative for pathogens. The purpose of this study was to examine the diagnostic yield of routine stool testing for O&P in a Canadian tertiary care centre and to estimate the potential clinical benefit of a positive result. Patients and Methods All stool samples sent to the central microbiology laboratory at London Health Sciences Centre were reviewed over a 5-year period ending January 2010. Initial screening was done by direct antigen testing using an enzyme immunoassay (EIA) technique followed by direct microscopy for negative results where there was a high index of suspicion and for positive results to rule out any concurrent parasites not included in the EIA kit. Pathogens identified were categorized and their potential susceptibility to metronidazole was estimated. No clinical data were available, as this was purely a utilization study. Results A total of 5812 stool tests were ordered. Of these, 5681 (97.7%) were completed. The most common reasons for an incomplete test were sample leakage (n = 38) and use of the incorrect collection kit (n = 32). Direct microscopy identified white blood cells in 17% of patients with positive testing. The most common pathogen was Giardia lamblia , which was detected in 45/83 (54%) of positive specimens. Entamoeba histolytica / Entamoeba dispar was identified in 16/83 (19%) and Cryptosporidium spp. in 10/83 (12%) of positive specimens. Microorganisms not thought to be pathogenic were identified in 7/83 (8%). Direct laboratory costs independent of labor were estimated at $1836 per clinically significant organism identified. Of the 77 specimens positive for pathogenic organisms, 62 (81%) were likely to be sensitive to treatment with metronidazole. Conclusion In a tertiary care centre, the diagnostic yield of routine testing of stool for O&P during the evaluation of patients with acute or chronic diarrhea is low. Most clinically significant positive results should be responsive to metronidazole, but empirical treatment is not encouraged. Strategies to identify patients with a higher likelihood of harboring pathogenic parasites and consideration of empiric metronidazole therapy for patients at highest risk merit further research.

Percutaneous endoscopic gastrostomy tube placement for end-stage palliation of malignant gastrointestinal obstructions

BACKGROUND/AIM

Decompression of malignant gastrointestinal obstructions is an uncommon indication for percutaneous endoscopic gastrostomy (PEG) tubes. The purpose of this study is to determine the efficacy of venting PEG tubes in relieving nausea and vomiting and assessing complications associated with tube placement.

PATIENTS AND METHODS

This study is a retrospective chart review of patients with PEG tubes placed to decompress malignant gastrointestinal obstructions between January 2005 and September 2010 by the gastroenterology service at our institute. Patient demographics, symptom relief, procedural complications, diet tolerability and home palliation were reviewed.

RESULTS

Seven PEG tubes were inserted to decompress malignant gastrointestinal obstructions. The mean patient age was 62 years (range 37-82 years). The underlying primary malignancies were small intestine (1), appendiceal (1), pancreatic (2), and colon (3) cancer. Gastric outlet obstruction was present in 3 (43%) patients while small bowel obstruction occurred in 4 (57%) patients. There was relief of nausea and vomiting in 6 (86%) patients. Procedural complications were present in 1 (14%) patient and involved superficial cellulitis followed by peristomal leakage. Patients with gastric outlet obstruction continued to have limited oral intake while patients with small bowel obstruction tolerated varying degrees of oral nutrition. Six (86%) patients were discharged home after PEG tube placement, but only 2 (33%) were able to undergo end-stage palliation at home without re-admission for hospital palliation.

CONCLUSIONS

Venting PEG tubes significantly reduce the symptoms of nausea and vomiting in patients with metastatic gastrointestinal obstruction due to primary gastrointestinal malignancies. Complications associated with tube placement were minimal.

Prospective study of clinical and histological safety of pure and uncontaminated Canadian oats in the management of celiac disease

BACKGROUND

Pure oats are safe for most patients with celiac disease, but concerns regarding contamination by other grains limit their consumption. The Canadian Celiac Association recently released guidelines governing the production of pure oats. The objective was to test the safety of a product manufactured under these guidelines.

METHODS

Fifteen adults with established, biopsy-confirmed celiac disease of ≥ 1 year duration were challenged with 350 g/wk of pure oats for 12 weeks. Symptom scores, weight, hemoglobin, ferritin, albumin, and tissue transglutaminase (tTG) were assessed at weeks 0, 6, and 12. Duodenal biopsies were obtained before and after oat challenge and assessed based on the modified Marsh-Oberhuber score. Compliance with a gluten-free diet was monitored with random food diaries.

RESULTS

Fifteen patients completed the study and were analyzed in intention-to-treat and per-protocol analyses. There were no significant changes in symptom scores, weight, hemoglobin, ferritin, or albumin during oat consumption. The tTG remained negative in all patients, and the histology scores did not significantly change during oat challenge. The only relapse occurred in a patient who became noncompliant with her gluten-free diet.

CONCLUSION

The findings support the safety of pure, uncontaminated oats manufactured under Canadian Celiac Association guidelines for patients with celiac disease.

A whole population study of gastrointestinal stromal tumors in the Czech Republic and Slovakia

Due to problems with identification and an incomplete understanding on the gastrointestinal stromal tumors (GIST) before 2001, there has been a lack of comprehensive long-term population-based studies on GIST epidemiology at present date. We used data from the online registry of Czech and Slovak GIST patients (http://gist.registry.cz/), which has been compiled and maintained since 2006 and involves patients diagnosed from the year 2000. 278 patients were included in this study. Most of the tumors fell into the high-risk category (58.7%), followed by the intermediate (21.4%), low (16.6%) and very low (3.3%) categories. Locations other than the small intestine and stomach had significantly higher contribution of high-risk tumors. The median time of overall survival was 93.2 months, 5-year relative survival was 78.3% overall, 71.9% for patients with high-risk tumors, 91.1% for intermediate patients, and 91.9% for patients from the low- and very low-risk category. The annual crude incidence between the years 2001-2005 was 0.52 cases per 100,000 inhabitants. The annual European ASR and World ASR were 0.44 and 0.31 per 100,000 inhabitants, respectively. Presented data generally correspond to the whole-population studies recently published, including actual data on epidemiology, clinical characteristics, and survival of patients. The registry helps in improving GIST diagnostics, knowledge about the properties and behaviour of tumors, communication among physicians, and, last but not least, therapeutical options and results.

Simple clinical predictors may obviate urgent endoscopy in selected patients with nonvariceal upper gastrointestinal tract bleeding

BACKGROUND

The validated Blatchford risk score (BRS) predicts outcomes in patients with nonvariceal upper gastrointestinal tract bleeding, before endoscopy; completion of the Rockall score requires endoscopy. The aims of this study were to predict whether the modified BRS (mBRS) can predict (1) endoscopic high-risk stigmata (HRS) and (2) rebleeding and mortality.

METHODS

Clinical and demographic characteristics on 1869 patients from 6 Canadian provinces were prospectively entered into the Registry for Upper GI Bleeding and Endoscopy database, recording 30-day rebleeding and mortality. The Rockall score and mBRS (hemoglobin level, hemodynamic instability, and presence of melena, liver disease, or cardiac failure; urea and syncope were not recorded) were calculated. Logistic regression was used to assess the association between an mBRS of 1 or less with HRS and with rebleeding and mortality.

RESULTS

The mean (SD) age of the patients was 66 (17) years, with 62% men and a mean of 2.5 comorbidities. Of the 1860 patients with 30-day rebleeding data, 334 (18.0%) rebled; 5.3% died. The mBRS was 0 in 3% and 1 or less in 9.8% of patients; HRS were seen in 31.0% of patients. An mBRS of 1 or less was associated with lower rebleeding (5% vs 19%; P<.001) and mortality (0.5% vs 5.8%; P=.003), and was significant in multivariate analysis for rebleeding (odds ratio, 0.24; 95% confidence interval, 0.12-0.48) and mortality (odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The HRS were less frequent when the mBRS was 1 or less (16.9% vs 32.7%; odds ratio, 0.4; 95% confidence interval, 0.3-0.6). Patients with a low mBRS with HRS had a low rebleeding rate (3.3%) and a lower apparent benefit from endoscopic therapy.

CONCLUSIONS

An mBRS of 1 or less identifies approximately 10% of patients with gastrointestinal tract bleeding with a low likelihood of having HRS and a low risk of adverse outcomes. A prospective randomized study is required to examine whether this subgroup of patients presenting after hours could be discharged safely from emergency departments with arrangements for (urgent) outpatient endoscopy.

Three-dimensional focus of attention for iterative cone-beam micro-CT reconstruction

Three-dimensional iterative reconstruction of high-resolution, circular orbit cone-beam x-ray CT data is often considered impractical due to the demand for vast amounts of computer cycles and associated memory. In this paper, we show that the computational burden can be reduced by limiting the reconstruction to a small, well-defined portion of the image volume. We first discuss using the support region defined by the set of voxels covered by all of the projection views. We then present a data-driven preprocessing technique called focus of attention that heuristically separates both image and projection data into object and background before reconstruction, thereby further reducing the reconstruction region of interest. We present experimental results for both methods based on mouse data and a parallelized implementation of the SIRT algorithm. The computational savings associated with the support region are substantial. However, the results for focus of attention are even more impressive in that only about one quarter of the computer cycles and memory are needed compared with reconstruction of the entire image volume. The image quality is not compromised by either method.

[Sleep and normality: usefulness for the practitioner]

About fifty percent of patients consulting their primary care physician complain of sleep disorders. Clinicians have to distinguish normal from abnormal sleep. For example, sleep normality is usually characterised by an apnea/hypopnea index < 5 h(-1) in absence of sleep symptoms. However such an index varies in relation with age, gender, body mass index, measurements methods In daily clinical practice, clinicians should look for sleep symptoms to define an abnormal sleep. More studies are needed to better define which patient will really benefit from a specific sleep therapy.

Comparative study of Dutch and German emergency-management models for near border nuclear accidents

Four institutes, all of which are involved in nuclear-emergency management in the Dutch-German border region, have compared their short-range dispersion and radiological dose models using scenarios consisting of single-station meteorology and two dispersed radionuclides. After adjustment of some of the parameters, the consequence of the differences in parameters on the effective dose was quantified at several stages from source to exposure. Results for the neutral stability class agreed within a factor of four. Variations in wet deposition of radioactive material, giving rise to external radiation from the ground, can cause significant variations to the effective dose. Furthermore, the way the different emergency-management tools model the atmospheric dispersion for a stable stability class in the horizontal plane can generate large differences. Finally, the methodology of calculating cloudshine is not comparable among the models, which causes the effective dose near the source to show large deviations for high emission sources.

Long-term Follow-up of Trigger Point Injections for Abdominal Wall Pain

OBJECTIVE: Abdominal wall pain (AWP) is a common yet often overlooked source of abdominal pain. Trigger point injections (TPI) into the abdominal wall have been tried in the past. Few studies have looked at the long-term outcome from these injections.

METHODS: A retrospective chart review was performed on 110 consecutive patients who received TPI for abdominal pain at the University of Western Ontario, London, Ontario. Outcomes from patients whose pain was due to AWP were determined. AWP was defined as fixed or localized pain and superficial or point tenderness (less than 2.5 cm diameter) or a positive Carnett sign (increased pain with tensing abdomen). The primary outcome was long-term efficacy of TPI. The number of diagnostic tests ordered to exclude AWP and the cost of investigating it were determined. Secondary analyses were done to determine if there were significant predictors of response to TPI.

RESULTS: Eighty-nine of 110 patients who received TPI met the criteria for AWP. In those who met the criteria for AWP, the average age was 42 years, 84% were female, and the average length of follow-up was 25 months. The primary outcome shows that, at follow-up, 77% had some or complete relief and 23% had no relief. An average of 4.3 diagnostic tests per patient were ordered to exclude other causes of abdominal pain. Secondary analyses show that meeting the criteria for AWP ( P<0.0005), the absence of gastrointestinal symptoms ( P<0.025), and an upper abdominal location of pain ( P<0.025) were statistically significant predictors of a positive response to TPI.

CONCLUSIONS: This study demonstrates that TPI, in patients who meet criteria for AWP, are effective over the long term.

[Contemporary view on the plasma natriuretic peptide assessment in the clinical practice]

Plasma natriuretic peptide assessment became a part of the routine clinical practice because of the laboratory methods development. After a brief historical overview of natriuretic peptides discovery, the article focuses on the brain natriuretic peptide (BNP). BNP plays an important role in the pathophysiology of many diseases of cardiovascular system due to its effects on the circulation (natriuresis, diuresis, inhibition of renin-angiotensin system, etc). The authors describe process of BNP synthesis, factors leading to its release into circulation. The main emphasis is done on the clinical significance of BNP and NT-proBNP assessment for the-diagnosis in cardiovascular diseases, risk stratification and monitoring of the treatment.

[Acetylsalicylic acid (ASA) resistance in patients with ischemic heart disease (IHD) as bioindicator of the treatment strategy]

BACKGROUND

The interest in aspirin resistance has been increasing during the last few years, with researchers earnestly pursuing alternative anti-platelet therapies and devices for measuring platelet aggregation. The recent studies suggest that 5-45% of patients taking aspirin do not experience adequate anti-platelet effects.

METHODS AND RESULTS

There is scant evidence proving that aspirin resistance has some clinical consequences. To assess the prevalence of aspirin resistance in patients with ischemic heart disease (IHD) two independent methods were used: platelet aggregation in platelet rich plasma (PRP) after induction by propylgallate (CPG), and assessment of platelet function by PFA 100 method. The study population consisted of 424 patients treated for IHD on the 2nd Dept. of Medicine, Teaching Hospital, Hradec Kralove. The age, gender, diagnosis and effect of therapy were characterized in this group of the patients. Daily ASA dose was 100 mg. We used two methods to monitor ASA treatment efficacy: a) thrombocyte aggregation after induction by CPG, b) the assessment of platelet function by PFA 100 method. a) Of the patients studied by CPG platelet aggregation, 51 (12.1%) pts were resistant to ASA dose 100 mg/day, and 32 (7.6%) pts remained resistant even after increasig the dose to 200 mg/day. In 80 (20%) pts, the daily ASA dose of less than 100 mg was sufficient to inhibit platelet function. b) Although the PFA-100 system is not able to detect the difference between low and high ASA dose, we found 53 (15.2%) patients aspirin resistant using this method.

CONCLUSIONS

In the patients with IHD treated with 100 mg of ASA per day, our study has shown that the prevalence of aspirin resistance was 12.1% using CPG method, and 15.2% using PFA-100 method. Aspirin resistance was dose dependent. Prevalence of ASA resistance in patients treated with 200 mg of ASA per day was only 7.6% using the CPG method.

[Ischemia-modified albumin: new marker of myocardial ischemia?]

The Albumin Cobalt Binding Test is a quantitative in vitro diagnostic test used on human serum that detects ischemia-modified albumin by measuring the cobalt binding capacity of albumin in human serum. Ischemia modified albumin is intended for use in conjunction with ECG and cardiac troponin as an aid to short term risk stratification of patients presenting with chest pain suggestive of cardiac origin. Thus, in patients with chest pain or equivalent symptoms suggestive of cardiac origin, with non-diagnostic ECG and normal troponin, a negative IMA can be used as an aid to rule out acute coronary syndrome (ACS) in low risk patients.

[Syncope in ventricular tachycardia as a first clinical sign of patent ductus arteriosus in an adulthood]

The case-report describes a 48-year-old-female patient with the patent ductus arteriosus with the following structural changes leading to the malignant arrhythmias manifested as a syncope. The patient was treated by Amplatzer occluder and the implantation of the cardioverter-defibrillator. The authors discuss the patent ductus arteriosus, arrhythmias and sudden cardiac death in the patients with the congenital heart disease in an adulthood.

Simulation of emission tomography using grid middleware for distributed computing

SimSET is Monte Carlo simulation software for emission tomography. This paper describes a simple but effective scheme for parallel execution of SimSET using NetSolve, a client-server system for distributed computation. NetSolve (version 1.4.1) is "grid middleware" which enables a user (the client) to run specific computations remotely and simultaneously on a grid of networked computers (the servers). Since the servers do not have to be identical machines, computation may take place in a heterogeneous environment. To take advantage of diversity in machines and their workloads, a client-side scheduler was implemented for the Monte Carlo simulation. The scheduler partitions the total decay events by taking into account the inherent compute-speeds and recent average workloads, i.e., the scheduler assigns more decay events to processors expected to give faster service and fewer decay events to those expected to give slower service. When compute-speeds and sustained workloads are taken into account, the speed-up is essentially linear in the number of equivalent "maximum-service" processors. One modification in the SimSET code (version 2.6.2.3) was made to ensure that the total number of decay events specified by the user is maintained in the distributed simulation. No other modifications in the standard SimSET code were made. Each processor runs complete SimSET code for its assignment of decay events, independently of others running simultaneously. Empirical results are reported for simulation of a clinical-quality lung perfusion study.

The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting

OBJECTIVES

From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting.

METHODS

Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes.

RESULTS

One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata.

CONCLUSIONS

These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.

Freshwater phytoplankton quantification by chlorophyll a: a comparative study of in vitro, in vivo and in situ methods

Standard ISO method for chlorophyll a quantification (extraction into ethanol, spectrophotometrical quantification at 665 and 750 nm), spectrofluorometry (reader for 96 wells, excitation 410 nm, emission 670 nm), and a submersible fluorescence probe for in situ phytoplankton quantification (excitation 410, 525, 570, 590, and 610 nm, emission 685 nm) were compared in different freshwater environments-reservoirs and rivers. The ISO method is accepted as a standard method but requires sample handling and transport to the laboratory. Spectrofluorometry is a sensitive method, even for natural phytoplankton populations. Nevertheless, it cannot be recommended for the quantification of cyanobacterial water blooms because colonial and filamentous species such as Microcystis, Anabaena, or Aphanizomenon display unacceptable variability (18-33%). The submersible probe featured high correlation with a standard ISO method (r=0.97, P<0.05). This probe can provide the selective measurement of technologically important phytoplankton groups like cyanobacteria, diatoms, green algae, and cryptophytes in lake vertical profiles of up to 100 m. The limitation of this instrument is the possible reabsorption of the light signal, e.g. in the presence of humic substances, or dense algal blooms. The use of submersible probes for in situ phytoplankton quantification can be recommended as a sensitive tool for water management, especially in the case of drinking water resources.

The effect of trimetazidine on C-reactive protein, cytokines and adhesion molecules in the course of acute myocardial infarction

The aim of this randomised, double-blind, placebo controlled, parallel group study was to assess the effect of trimetazidine (TMZ), a potent antiischaemic drug, on plasma C-reactive protein (C-RP), cytokine and adhesion molecule levels. The study population consists of 18 patients (16 males, 2 females, average age 56.45 +/- 10.97 years) with acute myocardial infarction admitted within 6 hours after onset of symptoms and treated with streptokinase. Blood samples were taken at 3-hour intervals during the time of treatment. All patients were randomised blindly using a centralised randomisation process, between trimetazidine (40 mg bolus i.v. then 60 mg per day for 48 hours intravenously in glucose infusion) or placebo group. Plasma C-RP level was significantly lower in TMZ group (39.5 mg/ml +/- 9.7 mg/ml) as compared to placebo (75.7 +/- 29.4 mg/ml, p < or = 0.001) and peaked 28 hours later in TMZ group. Plasma interleukin 6 (IL 6) level showed a sharp peak 9 hours after the onset of the symptoms in TMZ group (116.9 +/- 180.2 pg/ml vs. 45.4 +/- 37.9 pg/ml) and was increased up to 30 hours after the onset of the symptoms. Plasma interleukin 1 beta (IL 1 beta) was also higher in TMZ group notably 21 hours after the onset of symptoms (26.4 +/- 9.3 pg/ml vs. 16.2 +/- 2.4 pg/ml). TMZ group showed lower plasma E-selectin levels. Plasma IL 8, TNF alpha and ICAM 1 levels were without statistical significant differences. The present study demonstrates a significant reduction of plasma C-reactive protein level in the course of acute myocardial infarction treated with streptokinase and intravenous trimetazidine infusion compared with the group of patients without trimetazidine treatment.

Inflammatory response to acute myocardial infarction complicated by cardiogenic shock

We report a case of a 60-year-old man with acute myocardial infarction (AMI) treated using thrombolysis, and complicated by cardiogenic shock (CS). Plasma interleukin (IL) 1 beta, IL 6, IL 8, tumor necrosis factor alpha (TNF alpha), and soluble adhesion molecule (sICAM 1, sE-selectin) levels were measured at 3-h intervals. This observation showed the effect of AMI and CS on the plasma interleukin levels. Remarkable changes were found in the plasma TNF alpha level, which reached two significant peaks. The peak of the first elevation caused by AMI (80.11 pg/ml, vs. normal value 4.35 pg/ml, SD 21.3 pg/ml) was seen 6 h after the onset of the symptoms. After the period of significant decrease, TNF alpha level was increasing until the end of the observation period because of CS (the last TNF alpha level was 204.1 pg/ml). The plasma IL 1 beta level was continually increased during the period of observation (maximal IL 1 beta level 32.1 pg/ml, normal value < 10 pg/ml). The plasma IL 6 level reached the first peak caused by AMI nine hours after the onset of the symptoms (362.85 pg/ml, normal value (10 pg/ml). Because of CS, after the short period of decrease, the plasma IL 6 level was increasing until the end of the observation period (the last IL 6 level was 859.61 pg/ml). The plasma IL 8 level was also elevated throughout the time of observation (max. value 1652 pg/ml, vs. normal value < 30 pg/ml). The soluble adhesion molecule levels (sE-selectin and sICAM 1) were elevated throughout the period of observation without any significant peak.