Assessing Family Leave Policies and Pregnancy Outcomes Among Gastroenterologists: A Survey of Physicians in the American College of Gastroenterology

INTRODUCTION

Given variability in parental leave policies in gastroenterology (GI) with little data on outcomes, the American College of Gastroenterology conducted a survey to assess policies and outcomes.

METHODS

A survey was distributed to American College of Gastroenterology members with questions on demographics, fertility, pregnancy outcomes, and parental leave policies.

RESULTS

There were 796 responses, with 52.5% female individuals. Many (57%) delayed parenting. High rates of infertility (21%) and pregnancy complications (68%) were observed. Satisfaction with parental leave policies in GI was low (35%).

DISCUSSION

Our survey highlights the need for policies that support the well-being of our GI colleagues and families.

Incidence and risk factors for recurrence of ampullary adenomas after endoscopic papillectomy: Comparative analysis of familial adenomatous polyposis and sporadic ampullary adenomas in an international multicenter cohort

OBJECTIVES

Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA.

METHODS

We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease.

RESULTS

In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence.

CONCLUSION

Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients.

Prospective evaluation of the hemorrhoid energy treatment for the management of bleeding internal hemorrhoids

BACKGROUND

The hemorrhoid energy treatment (HET) system is a non-surgical bipolar electrotherapy device, which has previously demonstrated efficacy in the management of bleeding Grade I and II internal hemorrhoids; however, data is limited.

AIM

To prospectively assess the safety and efficacy of the HET device.

METHODS

This was an IRB-approved prospective study of 73 patients with Grade I or II internal hemorrhoids who underwent HET from March 2016 to June 2019. Patient factors and procedural data were obtained. A post-procedure questionnaire was administered by telephone to all patients at 1-wk and 3-mo following HET to assess for improvement and/or resolution of rectal bleeding and adherence to a stool softener regimen. A chart review was performed to observe recurrent symptoms and durability of response. Statistical analyses were performed using SPSS software (IBM; SPSS Version 25.0).

RESULTS

Seventy-three patients underwent HET during the study period. Mean post-HET follow-up was 1.89 years. Complete resolution of bleeding was reported in 65% at 1 wk (n = 48), with improvement in bleeding in 97.2% (n = 71) of patients. At 3-mo, resolution and/or improvement in bleeding was reported in 90% (n = 64) of patients. No procedure-related pain or adverse events were reported.

CONCLUSION

HET is well tolerated, safe and highly effective in the majority of our patients presenting with Grade I and II symptomatic internal hemorrhoids.

Safety and efficacy of a novel powered endoscopic debridement tissue resection device for management of difficult colon and foregut lesions: first multicenter U.S. experience

BACKGROUND AND AIMS

The EndoRotor, nonthermal, powered endoscopic debridement (PED) instrument (Interscope Inc, Whitinsville, Mass, USA), is a novel device used in the GI tract. It uses adjustable suction and a rotary cutting blade to precisely resect mucosal and submucosal tissue. Our aim was to assess the technical feasibility, safety, and efficacy of PED using the EndoRotor device.

METHODS

This was an Institutional Review Board-approved, multicenter, retrospective review. Patients underwent PED with the EndoRotor device from August 2018 to September 2019 at 4 high-volume U.S. centers. Patient demographics, indication for PED, and procedural and histopathologic data were recorded.

RESULTS

Thirty-four patients underwent PED (41 lesions). The most common indications for PED were colon polyps (18, 52.9%) and Barrett's esophagus (8, 23.5%). Most lesions (35, 85.4%) were resected previously for the same indication using standard techniques. Technical success was achieved in 97.6% of lesions (n = 40). Clinical success was achieved in most patients who underwent a follow-up examination (19, 79.2%). Intraprocedural bleeding (in 10 patients) was managed endoscopically; no EndoRotor-related perforations occurred. Three postprocedural adverse events occurred: self-limited chest pain in 1 patient and delayed bleeding in 2.

CONCLUSIONS

The EndoRotor is a novel, effective, and safe PED device for endoscopic resection of flat and polypoid lesions in the colon and foregut. It may have a promising role in the endoscopic management of naïve and scarred mucosal lesions based on this initial experience. Further prospective studies are needed to clarify its role in endoluminal resection.

Clinical efficacy of the over-the-scope clip device: A systematic review

BACKGROUND

The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.

AIM

To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.

METHODS

A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.

RESULTS

A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).

CONCLUSION

This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.

Outcomes of gastrointestinal bleeding in patients with left ventricular assist devices: a tertiary care experience

Background and study aims  Left ventricular assist device (LVAD) placement is a therapeutic modality for patients with end-stage heart failure. Gastrointestinal bleeding is a common complication following LVAD implantation. The aim of this study was to report our experience in management and outcomes of gastrointestinal bleeding in a large cohort of patients with LVADs. Patients and methods  We performed a retrospective review of all patients who underwent LVAD implantation at the University of Rochester Medical Center from January 2008 to June 2017. Data were collected on patient characteristics, clinical aspects of gastrointestinal bleeding events, and procedural interventions. A Cox proportional hazard model was utilized to identify potential risk factors for a gastrointestinal bleeding event. Results  During the study period, 345 patients underwent LVAD implantation. Of these, 125 patients (36.2 %) experienced 297 gastrointestinal bleeding events resulting in 533 endoscopic procedures. The diagnostic yield of endoscopy in determining a bleeding source was 49.5 %. If required, therapeutic interventions were successful in achieving homeostasis in 96.2 % of procedures. Our 30-day overall post-procedure adverse event (AE) rate was 6.6 %. Procedure-related (bleeding, infection, and perforation) AEs were very minimal (2.8 %). A Cox proportional hazard model indicated that older age at implant, female sex, African-American race, diabetes mellitus, and pulmonary hypertension were statistically significant predictors of a gastrointestinal bleeding event following LVAD implantation. Conclusions  LVAD patients have a high risk of gastrointestinal bleeding. Endoscopy was able to safely locate a bleeding lesion in approximately half of our patients and was successful in treating bleeding lesions in a majority of the cases.

Liquid nitrogen spray cryotherapy-based multimodal endoscopic management of dysplastic Barrett's esophagus and early esophageal neoplasia: retrospective review and long-term follow-up at an academic tertiary care referral center

BACKGROUND

Endoscopic eradication therapy of dysplastic Barrett's esophagus (BE) and early esophageal neoplasia has emerged as an effective treatment option. Data for the role of spray cryotherapy (SCT) in this setting is relatively limited.

OBJECTIVE

To evaluate the safety and long-term outcomes of SCT-based multimodal therapy in the management of dysplastic BE and early esophageal neoplasia.

DESIGN

Single-center, retrospective, cohort study.

SETTING

Academic, tertiary care center between August 2008 and February 2019.

METHODS

A retrospective chart review was conducted of the prospectively maintained endoscopic cryotherapy database at our center. Fifty-seven patients were identified who underwent SCT treatment for dysplastic BE and esophageal or Gastro-esophageal (GE) junction adenocarcinoma during the study period. Primary outcome was complete eradication of intestinal metaplasia (CE-IM); secondary outcome was complete eradication of dysplasia (CE-D).

RESULTS

A total of 171 SCT procedures were performed in 57 patients. The majority of patients were male (89.5%) with long-segment BE (93%; mean segment length 6.2 cm). Complete follow-up data was available for 56 of these 57 patients. 43.9% (25/57) of patients underwent radiofrequency ablation (RFA) during the course of treatment (e.g. after initiating SCT). 33.3% of patients (19/57) were RFA failures prior to SCT. Additionally, 68.4% (39/57) of patients underwent endoscopic resection (EMR) prior to SCT as part of our multimodal approach to treatment of BE dysplasia/neoplasia. Four patients (7%) are currently undergoing active ablation and/or EMR treatment. CE-IM was achieved in 75% (39/52) of patients, and CE-D in 98.1% (51/52). Mean duration of overall follow-up was 4.8 years, with mean CE-IM durability of 2.6 years.

LIMITATIONS

Single-center only, retrospective study design.

CONCLUSION

SCT-based multimodal endoscopic therapy can achieve very high CE-IM (75%) and CE-D (>98%) rates in a high-risk population with esophageal dysplasia and/or neoplasia.

Liquid Nitrogen Spray Cryotherapy is Associated With Less Postprocedural Pain Than Radiofrequency Ablation in Barrett's Esophagus: A Multicenter Prospective Study

GOALS AND BACKGROUND

Two common endoscopic therapies for eradication of dysplastic Barrett's esophagus are radiofrequency ablation (RFA) and liquid nitrogen spray cryotherapy (LNC). There is no data comparing postprocedural pain. This study aimed to compare the incidence of postprocedural pain between the 2 ablation modalities.

METHODS

This is a multicenter prospective study in which pain intensity scores and the presence of dysphagia were assessed immediately before and after treatment, 48 hours posttreatment and at 3 weeks posttreatment using validated instruments.

RESULTS

Of 94 patients, 35 underwent LNC and 59 underwent RFA [36 with focal radiofrequency ablation (RFA-F) and 23 with circumferential radiofrequency ablation (RFA-C)]. Immediately posttreatment, patients in the LNC group reported an average Numeric Pain Scale score that was lower than in the RFA groups [LNC 0.41 vs. RFA-F 1.18 (P=0.026), LNC 0.41 vs. RFA-C 1.38 (P=0.010)]. These differences persisted at 48 hours posttreatment [LNC 0.76 vs. RFA-F 1.77 (P=0.013), LNC 0.76 vs. RFA-C 1.73 (P=0.018)]. The odds of pain after RFA were at least 5 times greater than after LNC [immediately posttreatment odds ratio, 5.26 (95% confidence interval, 1.85-14.29) and 48 h posttreatment odds ratio, 5.56 (95% confidence interval, 2.27-14.29)]. There was no difference in dysphagia after treatment in either group, at any time point (P=0.429).

CONCLUSION

LNC was associated with less postprocedural pain when compared with RFA. These results help inform patients and physicians about the expected symptoms after ablative endotherapy.

Plasmid gene delivery to human keratinocytes through a fibrin-mediated transfection system

We have developed a matrix-mediated transfection system to deliver plasmids to human keratinocytes. The matrix is a soluble, self-hardening fibrin matrix (Tissucol), Baxter) that has been used clinically. Recently it has been shown that full thickness burn wounds can be successfully treated with a keratinocyte fibrin glue suspension. Further, it has been demonstrated that hEGF transfected cells accelerate wound healing. In this study, we inoculated the matrix with the hEGF expression plasmid and resuspended the matrix with either cultured or noncultured human keratinocytes. We obtained successful transfection rates of these cells (up to a 100-fold increase compared to controls containing no EGF expression plasmid) in vitro. After transplantation to full thickness wounds on athymic mice we were able to show a 180-fold increase in EGF concentration compared to controls, which persisted over the entire 7-day monitored period, decreasing from 180 to 20 pg/mL at day seven. This unique approach indicates the possible utility to combine a matrix for cell transplantation with a transfection system to release therapeutic proteins in vitro and in vivo.

Role of the subchondral vascular system in endochondral ossification: endothelial cell-derived proteinases derepress late cartilage differentiation in vitro

Endochondral ossification in growth plates proceeds through several consecutive steps of late cartilage differentiation leading to chondrocyte hypertrophy, vascular invasion, and, eventually, to replacement of the tissue by bone. The subchondral vascular system is essential for this process and late chondrocyte differentiation is subject to negative control at several checkpoints. Endothelial cells of subchondral blood vessels not only are the source of vascular invasion accompanying the transition of hypertrophic cartilage to bone but also produce factors overruling autocrine barriers against late chondrocyte differentiation. Here, we have determined that the action of proteases secreted by endothelial cells were sufficient to derepress the production of the hypertrophy-markers collagen X and alkaline phosphatase in arrested populations of chicken chondrocytes. Signalling by thyroid hormones was also necessary but endothelial factors other than proteinases were not. Negative signalling by PTH/PTHrP- or TGF-beta-receptors remained unaffected by the endothelial proteases whereas signalling by FGF-2 did not suppress, but rather activated late chondrocyte differentiation under these conditions. A finely tuned balance between chondrocyte-derived signals repressing cartilage maturation and endothelial signals promoting late differentiation of chondrocytes is essential for normal endochondral ossification during development, growth, and repair of bone. A dysregulation of this balance in permanent joint cartilage also may be responsible for the initiation of pathological cartilage degeneration in joint diseases.

[Gene therapy perspectives in modulation of wound healing]

A variety of reasons can afflict wound healing. Current research is focussed on the acceleration of wound healing by stimulating molecular processes. Gene therapy may offer completely new ways to treat chronic wounds. Possible advantages of gene therapeutic modulation of wound healing might be a long term efficiency, systemic or local regulation of gene expression and low side-effects. Current goals comprise the improvement of transfection efficiency and specificity. In vivo applications are therefore focussed on optimized inducible or even cell-type specific promotors, as well as on improved local application techniques. Studies from our laboratory demonstrate the possibility to combine modern cell culture techniques with different types of gene transfer. This enables the simultaneous grafting of manipulated cells to the wound with the continuous delivery of specific proteins of interest. Experimentally, this lead to accelerated closure of partial and full thickness animal wounds. Clinically, gene therapy for the treatment of chronic wounds seems to be a realistic goal within the next years and might be applicable for a variety of novel indications.

[Tissue engineering: possibilities and perspectives]

Successful tissue engineering requires intensive co-oporation between clinicians, biologists (cell culture, gene therapy), chemical engineers (biomaterials) and industrial partners. In case of wound healing tissue engineered constructs have already been applied successfully in burns and chronic wounds. In order to improve carrier and matrix function biomaterials still have to be optimized. The potential of such constructs might even be enhanced by gene therapeutical methods. The complex mammalian organism has to be considered as the gold standard and the model for perfect tissue engineering. The problem of vascularization of complex organs yet has to be solved. In general it seems to be more promising to substitute deficient components in vivo and to rely on modulating influences within the host organism rather than to create complex organs ex vivo.

Spatio-temporal distribution of chondromodulin-I mRNA in the chicken embryo: expression during cartilage development and formation of the heart and eye

To define genes specifically expressed in cartilage and during chondrogenesis, we compared by differential display-polymerase chain reaction (DD-PCR) the mRNA populations of differentiated sternal chondrocytes from chicken embryos with mRNA species modulated in vitro by retinoic acid (RA). Chondrocyte-specific gene expression is downregulated by RA, and PCR-amplified cDNAs from both untreated and RA-modulated cells were differentially displayed. Amplification products only from RNA of untreated chondrocytes were further analyzed, and a cDNA-fragment of the chondromodulin-I (ChM-I) mRNA was isolated. After obtaining full length cDNA clones, we have analyzed the mRNA expression patterns at different developmental stages by RNase protection assay and in situ hybridization. Analysis of different tissues and cartilage from 17-day-old chicken embryos showed ChM-I mRNA only in chondrocytes. During somitogenesis of the chicken embryo, ChM-I transcripts were detected in the notochord, the floor and the roof plate of the neural tube, and in cartilage precursor tissues such as the sclerotomes of the somites, the developing limbs, the pharyngeal arches, the otic vesicle, and the sclera. ChM-I continued to be expressed in differentiated cartilages derived from these tissues and also in noncartilaginous domains of the developing heart and retina. Thus, in the chicken, the expression of ChM-I is not restricted to mature cartilage but is already present during early development in precartilaginous tissues as well as in heart and eye.

Oxidative downmodulation of the transient K-current IA by intracellular arachidonic acid in rat hippocampal neurons

Membrane-permeable arachidonic acid (AA) is liberated in a Ca2+-dependent way inside cells. By using whole cell patch clamp we show that intracellular AA (1 pM) selectively reduces IA in rat hippocampal neurons, whereas extracellular application requires a 10(6)-fold concentration. The nonmetabolized AA analogue ETYA mimics the effect of AA that is blocked by ascorbic acid or intracellular glutathione, suggesting an intracellular oxidative mechanism. We conclude that intracellular AA is extremely potent in reducing IA by an oxidative mechanism, particularly during oxidative stress.

Terminal differentiation of chondrocytes is arrested at distinct stages identified by their expression repertoire of marker genes

During endochondral bone formation, cells in the emerging cartilaginous model transit through a cascade of several chondrocyte differentiation stages, each characterized by a specific expression repertoire of matrix macromolecules, until, as a final step, the hypertrophic cartilage is replaced by bone. In many permanent cartilage tissues, however, late differentiation of chondrocytes does not occur, due to negative regulation by the environment of the cells. Here, addressing the reason for the difference between chondrocyte fates in the chicken embryo sternum, cells from the caudal and cranial part were cultured separately in serum-free agarose gels with complements defined earlier that either permit or prevent hypertrophic development. Total RNA was extracted using a novel protocol adapted to agarose cultures, and the temporal changes in developmental stage-specific mRNA expression were monitored by Northern hybridization and phosphor image analysis. Kinetic studies of the mRNA accumulation not only showed significant differences between the expression patterns of cranial and caudal cultures after recovery, but also revealed two checkpoints of chondrocyte differentiation in keeping with cartilage development in vivo. Terminal differentiation of caudal chondrocytes is blocked at the late proliferative stage (stage Ib), while the cranial cells can undergo hypertrophic development spontaneously. The differentiation of cranial chondrocytes is reversible, since they can re-assume an early proliferative (stage Ia) phenotype under the influence of insulin, fibroblast growth factor-2 and transforming growth factor-beta in combination. Thus, the expression pattern in the latter culture resembles that of articular chondrocytes. We also provide evidence that the capacities of caudal and sternal chondrocytes to progress from the late proliferative (stage Ib) to hypertrophic stage (stage II) correlate with their differing abilities to express the Indian hedgehog gene.

Role of the subchondral vascular system in endochondral ossification: endothelial cells specifically derepress late differentiation in resting chondrocytes in vitro

Endochondral ossification in growth plates proceeds through several consecutive steps of late cartilage differentiation leading to chondrocyte hypertrophy, vascular invasion, and, eventually, to replacement of the tissue by bone. It is well established that the subchondral vascular system is pivotal in the regulation of this process. Cells of subchondral blood vessels act as a source of vascular invasion and, in addition, release factors influencing growth and differentiation of chondrocytes in the avascular growth plate. To elucidate the paracrine contribution of endothelial cells we studied the hypertrophic development of resting chondrocytes from the caudal third of chick embryo sterna in co-culture with endothelial cells. The design of the experiments prevented cell-to-cell contact but allowed paracrine communication between endothelial cells and chondrocytes. Under these conditions, chondrocytes rapidly became hypertrophied in vitro and expressed the stage-specific markers collagen X and alkaline phosphatase. This development also required signaling by thyroid hormone in synergy. Conditioned media could replace the endothelial cells, indicating that diffusible factors mediated this process. By contrast, smooth muscle cells, fibroblasts, or hypertrophic chondrocytes did not secrete this activity, suggesting that the factors were specific for endothelial cells. We conclude that endochondral ossification is under the control of a mutual communication between chondrocytes and endothelial cells. A finely tuned balance between chondrocyte-derived signals repressing cartilage maturation and endothelial signals promoting late differentiation of chondrocytes is essential for normal endochondral ossification during development, growth, and repair of bone. A dysregulation of this balance in permanent joint cartilage also may be responsible for the initiation of pathological cartilage degeneration in joint diseases.

Modulation of collagen gel contraction by decorin

The small dermatan sulphate protein decorin interacts via its core protein with fibrillar collagens, and its glycosaminoglycan chains were proposed to be capable of self-association. It was therefore of interest to study the role of decorin in the contraction of cell-populated collagen lattices. Stable transfection of dihydrofolate reductase-deficient CHO cells with decorin cDNA resulted in impaired collagen lattice contraction. Using normal human skin fibroblasts in serum-free cultures, inclusion of 0.3 microM decorin in the culture medium also led to a delayed collagen gel contraction. Protein-free dermatan sulphate and the dermatan sulphate-degrading enzyme chondroitin ABC lyase were ineffective. Potential interactions between dermatan sulphate chains were studied by gel filtration. A shift in the elution position of [35S]sulphate-labelled decorin-derived glycosaminoglycans by unlabelled decorin could be observed only when the chains were prepared by trypsin. Chains liberated by beta-elimination or by cathepsin C were eluted at identical positions in the presence or absence of decorin. It is therefore unlikely, that the effect of decorin on collagen-gel retraction is brought about solely by glycosaminoglycan-glycosaminoglycan interactions.

Biosynthesis and interactions of small chondroitin/dermatan sulphate proteoglycans

This review pays special attention to the structure and functions of two chondroitin/dermatan sulphate proteoglycans which are members of the family of small leucine-rich proteoglycans of the extracellular matrix. Novel data are presented indicating the importance of the core protein for the determination of the extent of glycosaminoglycan modification. Decorin as well as biglycan are able to associate specifically with type I collagen fibrils and to interact with several other components of the extracellular matrix. Recombinant fragments of both proteoglycans inhibit collagen fibrillogenesis. Evidence is presented for the functional diversity of decorin core protein. Considering the proposal of a glycosaminoglycan-glycosaminoglycan interaction, data are presented indicating that exclusively glycosaminoglycan chains containing a peptide moiety of more than two amino acids are able to interact with native decorin, suggesting that protein-protein or protein-glycosaminoglycan interactions are of importance in this respect, too. The interactions of decorin with growth factors are discussed, and it is shown that complexes of transforming growth factor-beta and decorin are still able to exhibit some but not all the specific effects of the uncomplexed cytokine.

Latent inhibition of granulocyte function by cyclosporine A

According to the literature, Cyclosporine A (CsA) is said to suppress specifically the activity of T and B cells. A significant influence on phagocyte function has been neglected. However, aggravated courses of bacterial and fungal infections have been frequently reported under the treatment with CsA, suggesting that a latent depression of phagocytic activity may possibly occur under clinical circumstances. Therefore, this study set out to assess whether CsA can also change granulocyte function under therapy conditions or not. Thirty-seven patients, 3 months-10 years after kidney transplantation being under immunosuppressive treatment with CsA + Prednisolone (n = 25), Azathioprine + Prednisolone (n = 6) and under Prednisolone alone (n = 6) underwent the study. 18 healthy persons served as a normal control group. Granulocyte function was tested ex vivo by chemiluminescence (CL) after stimulation with phorbolmyristate acetate (PMA) and with zymosan (zym) activated autologous or pool-serum. The obtained data were correlated to corresponding serum or plasma levels of CsA, human leukocyte elastase (HLE) and neopterin. Comparing the three therapy groups with the healthy control and with each other no differences could be seen in median CL values; but there was a significant (p = 0.05) negative correlation between CsA blood levels and maximum CL values of PMN. Such inhibition of CL could be calculated for zym but not for PMA stimulated PMN; suggesting that the CsA mediated inhibition of granulocyte function may be only partial and restricted to phagocytosis. In addition, a positive correlation between serum levels of human leukocyte elastase (HLE) and neopterin could be found. This indicates a simultaneous influence of CsA on both PMN and macrophages.

[The dry eye in kidney transplant patients]

Fifty-three patients with severe renal disease and/or kidney transplants underwent full ophthalmological examinations, including tear breakup time, Schirmer's test, and impression cytology of the conjunctivae. Although only some 50% of the patients complained of typical dry-eye symptoms, pathologic changes of the outer eye were found in almost 70%. Tear break-up times and Schirmer's test values were greatly reduced. Morphological changes of the conjunctiva were found in almost all the patients; in 50% of these cases the changes were moderate to severe.

A rapid laser immunonephelometric assay for serum amyloid A (SAA) and its application to the diagnosis of kidney allograft rejection

We set up a laser nephelometric assay for the quantitation of serum amyloid A (SAA) in human plasma. Therefore monospecific antibodies were raised in sheep and used in parallel to measure SAA concentrations by nephelometry and also by radial immunodiffusion, an assay usually applied for determination of SAA. The nephelometric method is precise, simple and unlike radial immunodiffusion results are obtained within an hour. The antigen concentrations determined both by laser nephelometry and radial immunodiffusion correlated highly (r = 0.98). As plasma SAA concentrations were reported to be a possible marker of kidney allograft rejection, the assay was applied to measure SAA concentrations in patients after kidney transplantation. Data were compared with clinical and other biochemical parameters. The period after kidney transplantation is reported for two cases, where SAA plasma concentrations were helpful in diagnosing allograft rejection. The rapid availability of the SAA plasma concentrations by nephelometry makes them a possible additional tool to decide quickly upon antirejection therapy.

[Persulfate asthma in hairdressers]

At the a two-year apprenticeship, a young female hairdresser developed rhinoconjunctivitis and bronchial asthma, induced by a hair bleach containing the substance persulphate. On each occasion, her symptoms occurred in the form of an immediate reaction. The causative role of the bleach was demonstrated with the aid of an inhalation challenge test. In addition, the prick test produced a positive reaction vis-a-vis persulphate. The long latency period and the positive prick test might militate in favour of an allergic pathomechanism.

[Cytomegalovirus-associated superinfection of the lung following kidney transplantation]

In a kidney-transplant patient, there was superinfection of the lungs by Klebsiella pneumoniae and Legionella pneumophilia with multiple necroses in the course of a primary cytomegalovirus infection. In a later phase of the disease, there was an opportunistic colonization of the necrotic cavities and the adjacent lung tissue by Aspergillus fumigatus and Candida albicans. The cytomegalovirus infection led to a pronounced cellular immunosuppression in the patient. This favored superinfections by bacteria and fungi. A poor nutritional state and a chronic lung disease are to be considered as predisposing risk factors.