Pepsinogen and Serum IgG Detection Is a Valuable Diagnostic Method for Helicobacter pylori Infection in a Low-Prevalence Country: A Report from Sri Lanka

The use of serum anti-Helicobacter pylori IgG and pepsinogen (PG) detection as a diagnostic method was evaluated in Sri Lanka. Gastric biopsies were performed (353 patients), and the prevalence of H. pylori infection was 1.7% (culture) and 2.0% (histology). IgG serology testing showed an area under the curve (AUC) of 0.922 (cut-off, 2.95 U/mL; specificity, 91.56%; sensitivity, 88.89%). Histological evaluation showed mild atrophy (34.3%), moderate atrophy (1.7%), metaplasia (1.7%), chronic gastritis (6.2%), and normal tissue (56%). The PGI/PGII ratio was significantly higher in H. pylori-negative patients (p < 0.01). PGII and PGI/PGII levels were lower in patients with metaplasia than in those with normal mucosa (p = 0.049 and p < 0.001, respectively). The PGI/PGII ratio best discriminated metaplasia and moderate atrophy (AUC 0.88 and 0.76, respectively). PGI and PGII alone showed poor discriminative ability, especially in mild atrophy (0.55 and 0.53, respectively) and chronic gastritis (0.55 and 0.53, respectively). The best cut-off to discriminate metaplasia was 3.25 U/mL (95.19% specificity, 83.33% sensitivity). Anti-H. pylori IgG and PG assessment (ABC method) was performed (group B, 2.0%; group A, 92.1%). The new cut-off more accurately identified patients with metaplasia requiring follow-up (group B, 5.4%). Assessment of anti-H. pylori IgG and PG is valuable in countries with a low prevalence of H. pylori infection.

Improvement in quality of life among Sri Lankan patients with haemorrhoids after invasive treatment: a longitudinal observational study

Background

Haemorrhoids is a common chronic disease that can significantly impact patients’ quality of life. Yet, few studies have evaluated health-related quality of life (HRQoL) of patients with haemorrhoids before and after treatment. This study investigated the HRQoL of patients with haemorrhoids before and after treatment and the change in HRQoL from baseline.

Methods

A prospective observational study of patients with haemorrhoids was conducted at two public hospitals in Kandy, Sri Lanka. Two questionnaires assessing symptom severity and haemorrhoid-specific QoL were administered at initial consultation and at 4- and 8-week follow-ups after treatment (sclerotherapy, rubber band ligation (RBL), haemorrhoidectomy or evacuation of haematoma). The primary outcome was the least squares (LS) change of HRQoL score from baseline, measured using the Short Health Scale adapted for Haemorrhoidal Disease (4 domains: symptom load, interference with daily activities, concern, general well-being).

Results

In 48 patients selected for this study, LS mean change from baseline showed significant improvement in HRQoL across all domains and total Short Health Scale adapted for Haemorrhoidal Disease score at 4- and 8-week follow-ups (P < 0.001). Difference in LS mean change from baseline also showed continued improvement of HRQoL from week 4 to week 8 (P < 0.010). ‘Concern’ showed greatest improvement at 4 and 8 weeks (P < 0.001). Averaged LS mean changes from baseline showed RBL had greater improvement of HRQoL compared with sclerotherapy (P = 0.004).

Conclusion

Patients with haemorrhoids had improved HRQoL after invasive treatment. Haemorrhoid-specific QoL is an important component of the extent of disease and can serve as an aid to guide treatment, assess outcomes and monitor disease.

Post-operative critical care and outcomes of limb replantation: experience in a developing country

Replantation is the treatment of choice for traumatic amputation. Its success rates vary, reaching 80% in world's best centres. This study analyses management practices of replantation in a regional centre in a developing country. Out of six replantations, four were successful. The median warm ischaemia time of the severed limb was 4.5h (range 1-13.5) and the median duration of general anaesthesia required for initial surgery was 6.25h (range 4.7-8.0). All patients needed intensive care following replantation for a median of 7 days (range 5-15). Pulse oximetry values were observed to be the same in the graft and the patient in successful cases. Two grafts failed. The median haemoglobin values on the 1st, 3rd and 5th post-operative day were 9.8, 7.0 and 8.4g/dl, respectively. The median platelet counts in the same time periods were 118x10(9), 68x10(9) and 205x10(9)L(-1). The median total fluid intake was 2.2, 3.1 and 3.4ml/kg/h on the 1st, 3rd and 5th post-operative day and the median urine output was 2.4, 2.6 and 2.7ml/kg/h, respectively. The observed post-surgical reduction in platelet count normalised by the 5th post-operative day. Higher fluid intake and lower haemoglobin levels appear to minimise the systemic effects of reperfusion injury, preventing the onset of renal failure and promoting graft perfusion. Pulse oximetry was a useful tool to assess graft perfusion and appear to offer a prognostic value. Three of the above 4 patients were traced for review 5 years later and had functioning grafts.

First experiences of pediatric kidney transplantation in Sri Lanka

KT is the most effective therapeutic option for ESRF. We present our first experiences in a developing country. All children who underwent kidney transplantation since the inception of this program in July 2004 until 30 September 2005 were studied. Their demographic data, operative and peri-operative details, graft and host survival, and drug compliance are described here. Data were collected from patient records and nursing observation records. Eleven children were transplanted during this period (median recipient age 10.75 yr, range: 8-16). The median age of the donors was 41 yr (range: 38-45) and was the mother in eight, father in two and uncle in one. The median (range) follow-up period following transplantation was 12.5 months (7-12). The vascular anastomotic site was aorta and inferior vena cava in nine patients and the cold ischemia time was mean (s.d.) 1.9 h (0.96). All patients received steroids, cyclosporine and MMF for immunosuppression. Hypotension, heart failure and septicemia were common medical complications. Four were treated for acute rejection. Vascular anastomotic leak, burst abdomen, intestinal obstruction, intra-abdominal leak of supra pubic catheter and vesico-ureteric junction obstruction were surgical complications. There were no graft losses or deaths. Despite limited resources good outcomes are possible following renal transplantation in children in developing countries.

The changes seen in balloon-injured porcine femoral arteries following sympathectomy

On the basis that vasoconstriction may contribute to restenosis following angioplasty, the influence of lumbar sympathectomy on the morphometry of femoral arteries after balloon injury was examined in a pig model. Twenty-six juvenile pigs underwent balloon de-endothelialization of the right femoral artery followed by an open bilateral lumbar sympathectomy (n = 14) or a sham sympathectomy (n = 12). Four weeks later flow was measured in femoral arteries. Animals were then killed and the femoral arteries were perfusion-fixed and harvested. Sympathectomy resulted in a significant (P = 0.04) increase in flow in both the injured (right) and uninjured (left) femoral arteries. Sympathectomy did not inhibit intimal thickening following balloon injury: median (interquartile range) intimal area was 0.4 mm2 (0.3-0.9) in the sympathectomy group versus 0.5 mm2 (0.4-0.9) in the sham group. Sympathectomy did, however, result in a significant (P = 0.02) increase in the lumen area: 1.1 mm2 (0.8-1.8) versus 0.7 mm2 (0.6-0.9). Sympathectomy may reduce vasospasm following angioplasty with the potential for clinical benefit.

Morphometric changes seen in balloon-injured porcine iliac arteries: the influence of sympathectomy on intimal hyperplasia and remodelling

OBJECTIVES

To assess the influence of lumbar sympathectomy on intimal thickening and arterial remodelling following balloon de-endothelialisation.

DESIGN

Experimental animal model with control and treated (sympathectomy) groups.

METHODS

Unilateral common iliac artery de-endothelialisation was performed in 36 male pigs using a 5F balloon catheter introduced via the profunda femoris artery. Bilateral lumbar sympathectomies were performed in 18 animals. Both iliac arteries were perfusion-fixed and harvested 4 weeks later. Arterial morphometry was assessed using computer image analysis.

RESULTS

Area measurements are expressed as median (interquartile range) in mm2. Balloon injury resulted in significant intimal thickening but no loss of lumen due to compensatory enlargement of the injured artery. Sympathectomy resulted in significant lumen enlargement (4.8 (2.6-6.3) vs. 1.9 (1.7-2.9)) in balloon-injured arteries. Although intimal thickening was reduced (0.9 (0.6-1.7) vs. 1.5 (0.9-2.0)), this was not statistically significant.

CONCLUSIONS

Sympathectomy increases lumen area 4 weeks after balloon injury to porcine iliac arteries. This effect is due to a combination of reduced arterial wall thickening and increased arterial size.

Monocyte chemoattractant protein-1 gene expression in injured pig artery coincides with early appearance of infiltrating monocyte/macrophages

Monocyte chemoattractant protein-1 (MCP-1) and interleukin-8 (IL-8) are potent chemokines which attract circulating monocytes and neutrophils respectively to inflamed tissues. JE/MCP-1 gene expression has been previously studied in rabbit aortae after endothelial denudation and the rapid appearance of this transcript was thought to precede emigration of phagocytes. We now report MCP-1 gene expression following de-endothelialization of iliac arteries in the pig, a species which can develop spontaneous atherosclerosis. Using Northern blot analysis, we demonstrated that MCP-1 mRNA was rapidly induced in pig arteries at 2 h and continued to increase to reach a maximum at 8 h before returning to low levels at 16-24 h after injury. The increase seen for MCP-1 mRNA at 8 h was also observed for IL-8 mRNA but was not apparent for growth-related gene expressions, urokinase-type plasminogen activator (u-PA), and plasminogen activator inhibitor-1 (PAI-1). Since smooth muscle cells, endothelial cells, and phagocytes are all capable of expressing MCP-1, we examined pig arteries for immunostaining using a monoclonal antibody to human MCP-1 (5D3-F7). At 8 h after injury, the predominant cell type staining positive for MCP-1 was the monocyte/macrophage. Staining was also observed in occasional scattered neutrophils, but MCP-1 protein could not be detected in smooth muscle cells or on extracellular matrix within the sensitivity constraints posed by our methodology. Our results are consistent with invading monocyte/macrophages having a major input into the production of this chemokine in the arterial wall following injury. The fact that MCP-1 expression accompanied monocyte/macrophage presence in damaged artery, rather than preceding it, is suggestive that continued MCP-1 expression is required for functions other than chemoattraction.

Vitamin D3 exacerbates intimal hyperplasia in balloon-injured arteries

Although a high dose of vitamin D3 is known to cause arterial calcification and degeneration, its effect on intimal hyperplasia has never been studied. The aim of this study was to examine the influence of a moderate supplement of vitamin D3 on intimal hyperplasia in the balloon-injured rat carotid artery. Forty-four rats had balloon injury to the carotid artery; 22 were given oral vitamin D3 supplementation (0.25 microgram kg-1 day-1). Animals were killed at 4 weeks and the carotid arteries were perfusion fixed and assessed morphometrically by means of computerized image analysis of transverse sections. Mean (s.e.m.) intimal area was significantly greater in the vitamin D3-treated animals than in controls: 0.92(0.05) versus 0.71(0.07) mm2 (P = 0.02). The area of the media of both injured and uninjured arteries was not influenced by vitamin D3 administration. A small dose of vitamin D3 resulted in significant exacerbation of intimal hyperplasia in this rat carotid artery model and raises the question of the role of dietary vitamin D3 in restenosis following vascular intervention.

Expression of transforming growth factor-beta1 (TGF-beta1) and urokinase-type plasminogen activator (u-PA) genes during arterial repair in the pig

OBJECTIVE

The transition from quiescence to proliferation in vitro is accompanied by early expression of proliferation-associated genes encoding products including cytokines and enzymes. We aimed to investigate TGF-beta1, u-PA and PAI-1 gene expressions in relation to proliferation and extracellular matrix (ECM) protein gene expressions in porcine arteries following injury.

METHODS

Right iliac arteries of juvenile pigs were de-endothelialised and harvested at fixed times after injury. RNA was then extracted and analysed by Northern blot analysis. RNA transcripts in thickened neointima of arteries were examined by in situ hybridisation using digoxygenin-labelled cDNA probes.

RESULTS

TGF-beta1, u-PA and PAI-1 transcripts were rapidly elevated (2-8h) and preceded a peak in histone mRNA at 24h after arterial injury. A second prolonged rise in TGF-beta1 mRNA at 4d coincided with elevated ECM protein gene expression. TGF-beta1 gene expression was detected in neointimal cells lining the arterial lumen at 4wk after injury.

CONCLUSIONS

The timings of increases in TGF-beta1, u-PA and PAI-1 mRNAs in injured arteries are consistent with contributions to processes prior to proliferation. The observation of a second protracted elevation in TGF-beta1 expression is supportive of an additional role in stimulation of ECM protein synthesis. Functional specialisation exists within the thickened intima of arteries late in repair.

Radiological predictors of response to renovascular reconstructive surgery

The aim of this study was to identify preoperative angiographic criteria which could be used to predict the response to renovascular reconstruction. A cohort of 49 patients who survived for more than 6 months after renovascular reconstruction was studied. All preoperative angiograms were reviewed independently and the renal size, degree of stenosis and the length of the lesion recorded. The response of blood pressure and renal function to surgery were correlated with the angiographic findings. We found that 58% of patients had long-term improvement in blood pressure control, though the response was significantly better where both kidneys were >12 cm in size (82%) compared with when both kidneys were < 12 cm (25%), P < 0.02. The degree of stenosis, while showing a trend towards a better blood pressure response with increasing stenosis, was not a statistically significant factor. None of the angiographic criteria examined could be used to predict the response in renal function. We have shown that the preoperative renal size is the only angiographic factor that may have some role in predicting the response of blood pressure to renovascular reconstruction.

The role of vitamin D3 in the aetiology of abdominal aortic aneurysms

Abdominal aortic aneurysms (AAAs) have traditionally been attributed to atherosclerosis, although there is increasing epidemiological, biochemical and genetic evidence that aneurysmal arterial disease is different from occlusive atherosclerosis. One of the most consistent biochemical findings in the aneurysmal aorta is a significant reduction in elastin protein; the cause, for this remains unclear. There is in vitro evidence that vitamin D3 (1,25 dihydrocholecalciferol) inhibits the production of elastin by smooth muscle cells. On the basis of this observation and the possibility that some subjects may be exposed to excess vitamin D3, the hypothesis that vitamin D3 may be a previously unrecognized aetiological factor in the pathogenesis of AAA is developed.

Short-term and long-term outcome following renovascular reconstruction

Experience with renovascular reconstruction at the authors' institution over the past 16 years has been reviewed. A total of 76 patients underwent surgical intervention for renovascular disease during that time. This included 62 patients with atherosclerosis and 11 with fibromuscular hyperplasia. Indications for intervention were uncontrolled hypertension in 42 patients and to restore renal impairment in eight. The procedure was performed for both indications in 26 patients. Ten patients (13%) died in the perioperative interval, which correlated strongly with comorbidity. With the exception of one patient, all deaths occurred in the elderly (> 65 years). While an increased mortality rate (P < 0.05) was observed in those undergoing concomitant surgical procedures (20%) as opposed to those undergoing renovascular reconstruction alone (6%), this was not an independent risk factor. Both the short term and long term response of hypertension control to renovascular reconstruction were favourable, with age < 60 years, shorter duration of hypertension (< 5 years) and diagnosis of fibromuscular hyperplasia predictive of a better response. Renovascular reconstruction, while successful in stabilizing or even improving renal function in the short term, was poor at restoring function long term, especially in the subgroup of patients whose serum creatinine was > 200 mumol/l at the time of reconstruction.