[Functional dyspepsia : update 2023]

Functional dyspepsia is defined by epigastric pain/burning, postprandial fullness and/or early satiety that have been present for at least six months before diagnosis, including three consecutive months, without evidence of an organic cause likely to explain these symptoms. The pathogenesis is complex and incompletely understood. The initial assessment includes a thorough history, physical examination, blood work, celiac disease serology and ruling out Helicobacter pylori infection. Most patients will undergo upper gastrointestinal endoscopy and abdominal ultrasound to exclude organic differential diagnoses. The therapy is multi-facetted and includes, among others, proton pump inhibitors, Helicobacter pylori eradication, herbal agents, and neuromodulators.

Eosinophilic Esophagitis beyond Eosinophils: An Emerging Phenomenon Overlapping with Eosinophilic Esophagitis, a CIA Update

Having long been considered the mainstay in eosinophilic esophagitis (EoE) diagnosis and pathogenesis, the role of eosinophils has been questioned and might be less important than previously thought. It is well known now that EoE is a Th2-mediated disease with many more disease features than eosinophilic infiltration. With more knowledge on EoE, less pronounced phenotypes or nuances of the disease have become apparent. In fact, EoE might be only the tip of the iceberg (and the most extreme phenotype) with several variant forms, at least three, lying on a disease spectrum. Although a common (food induced) pathogenesis has yet to be confirmed, gastroenterologists and allergologists should be aware of these new phenomena in order to further characterize these patients. In the following review, we discuss the pathogenesis of EoE, particularly those mechanisms beyond eosinophilic infiltration of the esophageal mucosa, non-eosinophilic inflammatory cell populations, the new disease entity EoE-like disease, variant forms of EoE, and the recently coined term mast cell esophagitis.

[Differential diagnosis and investigation of chronic diarrhea]

Chronic diarrhea is defined by a decrease in stool consistency and a bowel frequency of more than 3 times per day, lasting for at least 4 weeks. Multiple underlying causes may be responsible for chronic diarrhea. There are four main pathomechanisms for chronic diarrhea: osmotic diarrhea, secretory diarrhea, infectious diarrhea and bowel dysmotility. Overlaps between these mechanisms may exist. A stool collection over a 72-hour period frequently allows to classify diarrhea into one of these four entities. Such classification finally helps for the identification of underlying cause(s), thereby allowing rational diagnostic measures. It also limits the costs of diagnostic workup. This article aims to present the main causes of chronic diarrhea, the diagnostic steps to perform and to provide a guideline for clinicians in daily practice.

[Metabolism and therapeutic monitoring of azathioprine in gastroenterology and hepatology]

Azathioprine keeps an important place in the treatment of inflammatory bowel disease and autoimmune hepatitis. This molecule has a narrow therapeutic margin, associated with a risk of toxicity, particularly hematological and hepatic. Its complex metabolism is subject to genetic polymorphisms that are reflected in the inter-individual variability observed in the response to treatment and its tolerance profile. Hence, its use requires a good knowledge of this molecule. Treatment is initiated after a preliminary workup, followed by a progressive titration of the dosage while closely monitoring possible toxicities. Monitoring of blood levels of metabolites (including active ones) helps guide personalized dose adjustment.

[A practical guide to chronic inflammatory bowel disease]

Inflammatory bowel diseases (IBD) comprise Crohn's disease (CD) and ulcerative colitis (UC). IBD develops in patients with genetic susceptibility due to an aberrant response of the intestinal immune system toward gut microbiota. The prevalence of IBD is on the rise in Switzerland, with currently 1/250 persons affected, which corresponds to approximately 35,000 patients. Given the complexity of IBD, patients should be managed by a multidisciplinary team. This article focuses on IBD diagnosis and long-term follow-up.

Fatigue and sleepiness in night workers: preliminary results of an educational program

Background

Night work has negative effects on sleep, sleepiness and fatigue with repercussions in performance, safety and health. Therefore, implementing sleep hygiene educational intervention seems of tremendous importance to industries. The questions underlying this study were: 1) To what extent do shift workers experience risk levels of fatigue and sleepiness?; 2) May a sleep hygiene program be associated with improvements on fatigue and sleepiness?

Methods

The study was conducted in industry and employed a pre pos-test design using the Epworth's Sleepiness Scale and Chalder's Fatigue Scale. From 471 night workers assessed 45 participants at risk for fatigue and sleepiness (93.3% males), mean age of 31 years (SD = 7.3), were selected for the intervention, composed of four sessions along five months, delivered by the occupational medical doctor. The first three sessions, in small groups, focused in sleep literacy and sleep hygiene; the last one, individual, focused in clinical issues (personalized intervention plan).

Results

Results suggested that 9.6% (N = 45) of the night workers were at high risk (higher levels of fatigue and sleepiness). After intervention, paired T tests revealed significant decreases (p<.001) on mean values for fatigue from T0 (M = 6.67; SD = 2.23) to T1 (M = 4.78; SD = 3.02), and for sleepiness from T0 (M = 15.49; SD = 4.39) to T1 (M = 11.8; SD = 5.95). Along the intervention, participants pointed out family-related routines as an obstacle to daytime sleeping period.

Conclusions

Results support the importance of this educational program focused on sleep hygiene, in reducing sleepiness and fatigue. The program is now part of the occupational health procedures of the company but qualitative results also suggest the importance of including the family in the program, as an innovative procedure. In summary, education of night workers and their families is needed regarding sleep habits in order to promote safety and health in workplace.

Key messages

The sleep hygiene program implemented in permanent night workers allowed to reduce fatigue and sleepiness. Fatigue and sleepiness management improvements might contribute to reduce the risk of accidents in the workplace and increase the workers’ health condition.

Dissemination of bla OXA-370 gene among several Enterobacteriaceae species in Brazil

OXA-370 is a recently described OXA-48 variant that has only been described in a few Enterobacter spp. and Klebsiella pneumoniae isolates. The purpose of this study is to assess the prevalence of OXA-370-producing isolates in carbapenem-nonsusceptible Enterobacteriaceae recovered from 28 hospitals from Brazil. Real-time PCR was used to determine the presence of bla _NDM-1, bla _KPC-2, bla _VIM-type, bla _GES-type, bla _OXA-48-like, and bla _IMP-type genes. A total of 4,451 Enterobacteriaceae were screened. The gene bla _OXA-48-like was detected in 74 (2.5%) isolates, mostly of Enterobacter spp. (44.6% E. cloacae and 2.7% E. aerogenes) and Klebsiella spp. (31.1% K. pneumoniae and 6.7% K. oxytoca), followed by Escherichia coli, (6.7%), Morganella morganii, (2.7%), Citrobacter freundii (1.3%), Proteus mirabilis (1.3%), Providencia stuartii (1.3%), and Serratia spp. (1.3%). These isolates were from five hospitals, 67 (90.5%) from the hospital where the bla _OXA-370 was first described. Sequencing of bla _OXA-48-like was performed in 52 isolates, including E. cloacae, E. aerogenes, K. pneumoniae, K. oxytoca, E. coli, and C. freundii; all presenting 100% identity with bla _OXA-370. PFGE revealed the presence of distinct clones among K. pneumoniae, E. cloacae, K. oxytoca, and E. coli. Susceptibility rates to meropenem, imipenem, and ertapenem among OXA-370-producing isolates were 92.3%, 78.8%, 7.7% respectively; the MIC₅₀ /MIC₉₀ were 0.38/2 mg/L and 1/3 mg/L for meropenem and imipenem respectively. Overall, antimicrobial susceptibility analysis suggests that OXA-370 lacks carbapenemase activity. Our study demonstrated that the bla _OXA-370 gene is disseminated among several Enterobacteriaceae species and clones, indicating a high potential for dissemination.

High-intensity ultraendurance promotes early release of muscle injury markers

OBJECTIVE

To evaluate the impact of high-intensity ultraendurance (HIU) cycling, using it as a possible way to understand muscle injury kinetics and blood immune cells' release during high-intensity prolonged exercise

DESIGN

Male amateur triathletes enrolled during a cycling race of the International Bike Championship 800 km cycling relay (approximately 23 h). Each athlete alternately cycled 20-25 minutes until exhaustion and performed a total of approximately 200 km.

RESULTS

Creatine kinase levels in blood reached a 300% rise in a sigmoidal pattern, while lactate dehydrogenase levels increased by 30-40% following a hyperbolic pattern. Aspartate aminotransferase and alanine aminotransferase levels increased by up to 250% and 140%, respectively. Liver injury markers such as alkaline phosphatase and gamma-glutamyltransferase remained stable. Platelets increased by 20-30% from pre-exercise, and there was no change in haematocrit during the race. White blood cells rose by nearly 200%. Leucocytes rose 210% during the race, with a major component coming from neutrophils, which increased more than 300%. Triacylglycerol levels were decreased at the finish and total cholesterol levels remained unchanged. Urate increased (by up to 35%) during the first half of the race, and urea levels increased with a different pattern, increasing by 45% in the second half.

CONCLUSIONS

This study showed the blood appearance kinetics of muscle injury markers and some metabolites. It is suggested that the increase in these enzymes came primarily from muscle damage, rather than liver damage, and that white blood cells are selectively mobilised independently of haemoconcentration. The early appearance of muscle injury markers in this kind of exercise was also shown.

Bladder acellular matrix graft: in vivo functional properties of the regenerated rat bladder

The purpose of this study was to determine whether the rat urinary bladder augmented by an acellular matrix graft can restore the bladder's low-pressure reservoir function and preserve normal micturition. After partial cystectomy (> 50%) and grafting with the bladder acellular matrix graft (BAMG), storage and voiding functions were monitored in 20 rats by means of a specially designed "micturition cage," leak-point cystography, and cystometry. After 4 months, sections (n = 6) were examined histologically to evaluate regeneration of bladder wall components within the BAMG. Bladder capacity and compliance increased progressively and were significantly higher in the grafted animals than in controls (partial cystectomy only), and volumes per void were significantly higher than in either control or normal animals. At 4 months, the regenerated urothelium, smooth muscle, blood vessels and nerves within the BAMG were qualitatively identical to normal bladder wall. Augmentation cystoplasty with the homologous BAMG leads to morphologic and functional rat bladder regeneration, thus enhancing low-pressure reservoir function and preserving normal micturition.

In vitro functional properties of the rat bladder regenerated by the bladder acellular matrix graft

PURPOSE

To assess the response of rat urinary bladder regenerated by the homologous bladder acellular matrix graft (BAMG) to in vitro electrical and pharmacologic stimuli.

MATERIALS AND METHODS

In Sprague-Dawley rats, partial cystectomy (>50%) was performed, followed by BAMG augmentation cystoplasty. After 4 months, organ bath studies of tissue strips in 10 were used to compare the contractility of the BAMG regenerates and the corresponding host detrusor smooth muscle.

RESULTS

The BAMG regenerates exhibited contractile activity to electrical field stimulation and a qualitatively identical pattern of response to muscarinic, purinergic, alpha- and beta-adrenergic drug administration and nitric oxide. At 4 months after surgery, the maximum forces of contraction of the BAMG regenerates to carbachol stimulation amounted to close to 80% of the host bladder response. With electrical field stimulation, they equaled 44% and 62% of the host bladder response after 2.5 and 4 months, respectively. Histological and immunohistochemical studies confirmed the presence of receptors for neurotransmitters that these functional in vitro studies implied.

CONCLUSIONS

The present study provides further evidence that augmentation cystoplasty with the BAMG leads to functional regeneration of the rat bladder detrusor smooth muscle.

Functional rat bladder regeneration through xenotransplantation of the bladder acellular matrix graft

OBJECTIVE

To determine the decreased antigenicity of the bladder acellular matrix graft (BAMG) through xenotransplantation and to assess the in vivo and in vitro functional properties of the rat urinary bladder thus regenerated.

MATERIALS AND METHODS

After partial cystectomy (> 50%), BAMGs prepared from hamster, rabbit and dog urinary bladders were grafted to male and female Sprague-Dawley rats; 10 control rats underwent partial cystectomy only. Urinary storage and voiding function were monitored in 15 animals using a specially designed 'micturition cage' and cystometry. After 4 months, organ-bath studies and histological techniques were used to evaluate bladder regeneration in vitro in the grafted animals.

RESULTS

Clinically relevant antigenicity was not evident; no animal died from rejection and all bladder wall components regenerated in all BAMG xenografts. However, the degree and quality of regeneration varied. Muscularization, peak pressure, and bladder capacity were higher in the hamster BAMG-grafted animals, whereas in vitro contractility and compliance were best in the dog BAMG-regenerated bladders. All grafted bladders had significantly better capacity and compliance than the autoregenerated bladders after partial cystectomy alone.

CONCLUSIONS

The present in vivo and in vitro studies show that BAMG-augmentation cystoplasty can lead to morphological and functional regeneration of the rat bladder, preserving its low-pressure reservoir function. Because BAMG-regenerated bladders show functional innervation that is similar to normal bladders, they can work in coordination with the host bladder components, thus generating adequate intravesical pressure to produce sustained voiding. The decreased antigenicity makes heterologous BAMG transplants feasible without immunosuppression.