Evaluation of early single dose vaccination on swine influenza A virus transmission in piglets: From experimental data to mechanistic modelling

Swine influenza A virus (swIAV) is a major pathogen affecting pigs with a huge economic impact and potentially zoonotic. Epidemiological studies in endemically infected farms permitted to identify critical factors favoring on-farm persistence, among which maternally-derived antibodies (MDAs). Vaccination is commonly practiced in breeding herds and might be used for immunization of growing pigs at weaning. Althoughinterference between MDAs and vaccination was reported in young piglets, its impact on swIAV transmission was not yet quantified. To this aim, this study reports on a transmission experiment in piglets with or without MDAs, vaccinated with a single dose injection at four weeks of age, and challenged 17 days post-vaccination. To transpose small-scale experiments to real-life situation, estimated parameters were used in a simulation tool to assess their influence at the herd level. Based on a thorough follow-up of the infection chain during the experiment, the transmission of the swIAV challenge strain was highly dependent on the MDA status of the pigs when vaccinated. MDA-positive vaccinated animals showed a direct transmission rate 3.6-fold higher than the one obtained in vaccinated animals without MDAs, estimated to 1.2. Vaccination nevertheless reduced significantly the contribution of airborne transmission when compared with previous estimates obtained in unvaccinated animals. The integration of parameter estimates in a large-scale simulation model, representing a typical farrow-to-finish pig herd, evidenced an extended persistence of viral spread when vaccination of sows and single dose vaccination of piglets was hypothesized. When extinction was quasi-systematic at year 5 post-introduction in the absence of sow vaccination but with single dose early vaccination of piglets, the extinction probability fell down to 33% when batch-to-batch vaccination was implemented both in breeding herd and weaned piglets. These results shed light on a potential adverse effect of single dose vaccination in MDA-positive piglets, which might lead to longer persistence of the SwIAV at the herd level.

Serological Evidence of Backyard Pig Exposure to Highly Pathogenic Avian Influenza H5N8 Virus during 2016-2017 Epizootic in France

In autumn/winter 2016-2017, HPAI-H5N8 viruses belonging to the A/goose/Guandong/1/1996 (Gs/Gd) lineage, clade 2.3.4.4b, were responsible for outbreaks in domestic poultry in Europe, and veterinarians were requested to reinforce surveillance of pigs bred in HPAI-H5Nx confirmed mixed herds. In this context, ten pig herds were visited in southwestern France from December 2016 to May 2017 and serological analyses for influenza A virus (IAV) infections were carried out by ELISA and hemagglutination inhibition assays. In one herd, one backyard pig was shown to have produced antibodies directed against a virus bearing a H5 from clade 2.3.4.4b, suggesting it would have been infected naturally after close contact with HPAI-H5N8 contaminated domestic ducks. Whereas pigs and other mammals, including humans, may have limited sensitivity to HPAI-H5 clade 2.3.4.4b, this information recalls the importance of implementing appropriate biosecurity measures in pig and poultry farms to avoid IAV interspecies transmission, a prerequisite for co-infections and subsequent emergence of new viral genotypes whose impact on both animal and human health cannot be predicted.

Evaluation of the Pathogenicity and the Escape from Vaccine Protection of a New Antigenic Variant Derived from the European Human-Like Reassortant Swine H1N2 Influenza Virus

The surveillance of swine influenza A viruses in France revealed the emergence of an antigenic variant following deletions and mutations that are fixed in the HA-encoding gene of the European human-like reassortant swine H1N2 lineage. In this study, we compared the outcomes of the parental (H1huN2) and variant (H1huN2Δ146-147) virus infections in experimentally-inoculated piglets. Moreover, we assessed and compared the protection that was conferred by an inactivated vaccine currently licensed in Europe. Three groups of five unvaccinated or vaccinated piglets were inoculated with H1huN2 or H1huN2Δ146-147 or mock-inoculated, respectively. In unvaccinated piglets, the variant strain induced greater clinical signs than the parental virus, in relation to a higher inflammatory response that involves TNF-α production and a huge afflux of granulocytes into the lung. However, both infections led to similar levels of virus excretion and adaptive (humoral and cellular) immune responses in blood. The vaccinated animals were clinically protected from both infectious challenges and did not exhibit any inflammatory responses, regardless the inoculated virus. However, whereas vaccination prevented virus shedding in H1huN2-infected animals, it did not completely inhibit the multiplication of the variant strain, since live virus particles were detected in nasal secretions that were taken from H1huN2Δ146-147-inoculated vaccinated piglets. This difference in the level of vaccine protection was probably related to the poorer ability of the post-vaccine antibodies to neutralize the variant virus than the parental virus, even though post-vaccine cellular immunity appeared to be equally effective against both viruses. These results suggest that vaccine antigens would potentially need to be updated if this variant becomes established in Europe.

Bidirectional Human-Swine Transmission of Seasonal Influenza A(H1N1)pdm09 Virus in Pig Herd, France, 2018

In 2018, a veterinarian became sick shortly after swabbing sows exhibiting respiratory syndrome on a farm in France. Epidemiologic data and genetic analyses revealed consecutive human-to-swine and swine-to-human influenza A(H1N1)pdm09 virus transmission, which occurred despite some biosecurity measures. Providing pig industry workers the annual influenza vaccine might reduce transmission risk.

Assessment of Influenza D Virus in Domestic Pigs and Wild Boars in France: Apparent Limited Spread within Swine Populations Despite Serological Evidence of Breeding Sow Exposure

In order to assess influenza D virus (IDV) infections in swine in France, reference reagents were produced in specific pathogen free pigs to ensure serological and virological analyses. Hemagglutination inhibition (HI) assays were carried out on 2090 domestic pig sera collected in 2012-2018 in 102 farms. Only 31 sera from breeding sows sampled in 2014-2015 in six farrow-to-finish herds with respiratory disorders contained IDV-specific antibodies. In two of them, within-herd percentage of positive samples (73.3% and 13.3%, respectively) and HI titers (20-160) suggested IDV infections, but virus persistence was not confirmed following new sampling in 2017. All growing pigs tested seronegative, whatever their age and the sampling year. Moreover, PB1-gene RT-qPCR performed on 452 nasal swabs taken in 2015-2018 on pigs with acute respiratory syndrome (137 farms) gave negative results. In Corse, a Mediterranean island where pigs are mainly bred free-range, 2.3% of sera (n = 177) sampled on adult pigs in 2013-2014 obtained low HI titers. Finally, 0.5% of sera from wild boars hunted in 2009-2016 (n = 644) tested positive with low HI titers. These results provide the first serological evidence that sows were exposed to IDV in France but with a limited spread within the swine population.

Virological and epidemiological patterns of swine influenza A virus infections in France: Cumulative data from the RESAVIP surveillance network, 2011-2018

Swine influenza A viruses (swIAVs) cause acute respiratory syndromes in pigs and may also infect humans. Following the 2009 pandemic, a network was established in France to reinforce swIAV monitoring. This study reports virological and epidemiological data accumulated through passive surveillance conducted during 1,825 herd visits from 2011 to 2018. Among them, 887 (48.6 %) tested swIAV-positive. The proportion of positive cases remained stable year-on-year and year-round. The European avian-like swine H1N1 (H1_avN1) virus was the most frequently identified (69.6 %), and was widespread across the country. The European human-like reassortant swine H1N2 (H1_huN2) virus accounted for 22.1 % and was only identified in the north-western quarter and recently in the far north. The 2009 pandemic H1N1 (H1N1pdm) virus (3.6 %) was detected throughout the country, without settling in areas of higher pig densities. Its proportion increased in winter, during the seasonal epidemics in humans. The European human-like reassortant swine H3N2 as well as H1_avN2 viruses were identified sporadically. In up to 30 % of swIAV-positive cases, pigs exhibited clinical signs of high intensity, regardless of the viral subtype and vaccination program. The recurrent pattern of the disease, i.e., an endemic infection at the herd level, was reported in 41% of cases and mainly affected post-weaning piglets (OR = 5.11 [3.36-7.76]). Interestingly, the study also revealed a significant association between the recurrent pattern and sow vaccination (OR = 1.96 [1.37-2.80]). Although restricted to the studied pig population, these results bring new knowledge about swIAV dynamics and infection patterns in pig herds in France.

Virus persistence in pig herds led to successive reassortment events between swine and human influenza A viruses, resulting in the emergence of a novel triple-reassortant swine influenza virus

This report describes the detection of a triple reassortant swine influenza A virus of H1_avN2 subtype. It evolved from an avian-like swine H1_avN1 that first acquired the N2 segment from a seasonal H3N2, then the M segment from a 2009 pandemic H1N1, in two reassortments estimated to have occurred 10 years apart. This study illustrates how recurrent influenza infections increase the co-infection risk and facilitate evolutionary jumps by successive gene exchanges. It recalls the importance of appropriate biosecurity measures inside holdings to limit virus persistence and interspecies transmissions, which both contribute to the emergence of new potentially zoonotic viruses.

Molecular subtyping of European swine influenza viruses and scaling to high-throughput analysis

BACKGROUND

Swine influenza is a respiratory infection of pigs that may have a significant economic impact in affected herds and pose a threat to the human population since swine influenza A viruses (swIAVs) are zoonotic pathogens. Due to the increasing genetic diversity of swIAVs and because novel reassortants or variants may become enzootic or have zoonotic implications, surveillance is strongly encouraged. Therefore, diagnostic tests and advanced technologies able to identify the circulating strains rapidly are critically important.

RESULTS

Several reverse transcription real-time PCR assays (RT-qPCRs) were developed to subtype European swIAVs in clinical samples previously identified as containing IAV genome. The RT-qPCRs aimed to discriminate HA genes of four H1 genetic lineages (H1_av, H1_hu, H1_huΔ146-147, H1pdm) and one H3 lineage, and NA genes of two N1 lineages (N1, N1pdm) and one N2 lineage. After individual validation, each RT-qPCR was adapted to high-throughput analyses in parallel to the amplification of the IAV M gene (target for IAV detection) and the β-actin gene (as an internal control), in order to test the ten target genes simultaneously on a large number of clinical samples, using low volumes of reagents and RNA extracts.

CONCLUSION

The RT-qPCRs dedicated to IAV molecular subtyping enabled the identification of swIAVs from the four viral subtypes that are known to be enzootic in European pigs, i.e. H1_avN1, H1_huN2, H3N2 and H1N1pdm. They also made it possible to discriminate a new antigenic variant (H1_huN2_Δ146-147) among H1_huN2 viruses, as well as reassortant viruses, such as H1_huN1 or H1_avN2 for example, and virus mixtures. These PCR techniques exhibited a gain in sensitivity as compared to end-point RT-PCRs, enabling the characterization of biological samples with low genetic loads, with considerable time saving. Adaptation to high-throughput analyses appeared effective, both in terms of specificity and sensitivity. This new development opens novel perspectives in diagnostic capacities that could be very useful for swIAV surveillance and large-scale epidemiological studies.

Development of 100 Mo -containing scintillating bolometers for a high-sensitivity neutrinoless double-beta decay search

This paper reports on the development of a technology involving 100 Mo -enriched scintillating bolometers, compatible with the goals of CUPID, a proposed next-generation bolometric experiment to search for neutrinoless double-beta decay. Large mass ( ∼ 1 kg ), high optical quality, radiopure 100 Mo -containing zinc and lithium molybdate crystals have been produced and used to develop high performance single detector modules based on 0.2-0.4 kg scintillating bolometers. In particular, the energy resolution of the lithium molybdate detectors near the Q-value of the double-beta transition of 100 Mo (3034 keV) is 4-6 keV FWHM. The rejection of the α -induced dominant background above 2.6 MeV is better than 8 σ . Less than 10 μ Bq/kg activity of 232 Th ( 228 Th ) and 226 Ra in the crystals is ensured by boule recrystallization. The potential of 100 Mo -enriched scintillating bolometers to perform high sensitivity double-beta decay searches has been demonstrated with only 10 kg × d exposure: the two neutrino double-beta decay half-life of 100 Mo has been measured with the up-to-date highest accuracy as T 1 / 2 = [6.90 ± 0.15(stat.) ± 0.37(syst.)] × 10 18 years . Both crystallization and detector technologies favor lithium molybdate, which has been selected for the ongoing construction of the CUPID-0/Mo demonstrator, containing several kg of 100 Mo .

Maternally-derived antibodies do not prevent transmission of swine influenza A virus between pigs

A transmission experiment involving 5-week-old specific-pathogen-free (SPF) piglets, with (MDA(+)) or without maternally-derived antibodies (MDA(-)), was carried out to evaluate the impact of passive immunity on the transmission of a swine influenza A virus (swIAV). In each group (MDA(+)/MDA(-)), 2 seeders were placed with 4 piglets in direct contact and 5 in indirect contact (3 replicates per group). Serological kinetics (ELISA) and individual viral shedding (RT-PCR) were monitored for 28 days after infection. MDA waning was estimated using a nonlinear mixed-effects model and survival analysis. Differential transmission rates were estimated depending on the piglets' initial serological status and contact structure (direct contact with pen-mates or indirect airborne contact). The time to MDA waning was 71.3 [52.8-92.1] days on average. The airborne transmission rate was 1.41 [0.64-2.63] per day. The compared shedding pattern between groups showed that MDA(+) piglets had mainly a reduced susceptibility to infection compared to MDA(-) piglets. The resulting reproduction number estimated in MDA(+) piglets (5.8 [1.4-18.9]), although 3 times lower than in MDA(-) piglets (14.8 [6.4-27.1]), was significantly higher than 1. Such an efficient and extended spread of swIAV at the population scale in the presence of MDAs could contribute to swIAV persistence on farms, given the fact that the period when transmission is expected to be impacted by the presence of MDAs can last up to 10 weeks.

Dynamics of influenza A virus infections in permanently infected pig farms: evidence of recurrent infections, circulation of several swine influenza viruses and reassortment events

Concomitant infections by different influenza A virus subtypes within pig farms increase the risk of new reassortant virus emergence. The aims of this study were to characterize the epidemiology of recurrent swine influenza virus infections and identify their main determinants. A follow-up study was carried out in 3 selected farms known to be affected by repeated influenza infections. Three batches of pigs were followed within each farm from birth to slaughter through a representative sample of 40 piglets per batch. Piglets were monitored individually on a monthly basis for serology and clinical parameters. When a flu outbreak occurred, daily virological and clinical investigations were carried out for two weeks. Influenza outbreaks, confirmed by influenza A virus detection, were reported at least once in each batch. These outbreaks occurred at a constant age within farms and were correlated with an increased frequency of sneezing and coughing fits. H1N1 and H1N2 viruses from European enzootic subtypes and reassortants between viruses from these lineages were consecutively and sometimes simultaneously identified depending on the batch, suggesting virus co-circulations at the farm, batch and sometimes individual levels. The estimated reproduction ratio R of influenza outbreaks ranged between 2.5 [1.9-2.9] and 6.9 [4.1-10.5] according to the age at infection-time and serological status of infected piglets. Duration of shedding was influenced by the age at infection time, the serological status of the dam and mingling practices. An impaired humoral response was identified in piglets infected at a time when they still presented maternally-derived antibodies.

Influenza A(H1N1)pdm09 virus in pigs, Réunion Island

During 2009, pandemic influenza A(H1N1)pdm09 virus affected humans on Réunion Island. Since then, the virus has sustained circulation among local swine herds, raising concerns about the potential for genetic evolution of the virus and possible retransmission back to humans of variants with increased virulence. Continuous surveillance of A(H1N1)pdm09 infection in pigs is recommended.

Yield and impact of emergency capsule enteroscopy in severe obscure-overt gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Patients with obscure-overt gastrointestinal bleeding (OOGIB) are defined by overt hemorrhage and negative upper and lower endoscopy findings. At present, the place of emergency capsule enteroscopy in patients with severe OOGIB is unknown. The aim of this study was to assess the diagnostic yield and the impact of emergency capsule enteroscopy on further management in patients with severe OOGIB.

PATIENTS AND METHODS

Between 2003 and 2010, we retrospectively included all patients with severe OOGIB who underwent emergency capsule enteroscopy in the 24-48 h following negative urgent upper and lower endoscopy. Severe OOGIB was defined by ongoing bleeding with hemodynamic instability and/or the need for significant red blood cell transfusion.

RESULTS

Out of 5744 patients hospitalized in our Gastrointestinal Bleeding Unit, 55 (1%) presented with severe OOGIB and underwent emergency capsule enteroscopy. Capsule enteroscopy showed blood in 41 patients (75%) and lesions in 37 patients (67%). Findings included small bowel angiodysplasia in 19 patients (35%), ulcers in 7 (13%), tumors in 5 (9%), small-bowel varices in 2 (3%), cecum angiodysplasia in 4 (7%), fresh blood in small bowel without identified lesion in 12 (22%). Specific diagnostic and therapeutic procedures were undertaken in 78 % of patients. Further management included endoscopy (54%), surgery (22%), and radiology (2%).

CONCLUSIONS

Emergency capsule enteroscopy identified bleeding lesions in 67 % of patients with severe OOGIB. Emergency capsule enteroscopy seems to be a promising diagnostic tool with a subsequent impact on clinical management in patients with severe OOGIB.

Irritable bowel syndrome is more frequent in patients hospitalized for ischaemic colitis: results of a case-control study

It has been suspected that there is an epidemiological link between irritable bowel syndrome (IBS) and ischaemic colitis (IC). We performed a retrospective case-control study to compare the frequency of IBS in patients hospitalized for IC compared with that of patients with peptic ulcer bleeding. Cases were patients with a first episode of IC and controls were patients with a first episode of peptic ulcer bleeding, matched to cases for sex and 10-year age-class. Diagnosis of IBS was based on medical information extracted from hospital medical files and a standard self-questionnaire. The association between IBS and IC was tested using Mc Nemar's paired odds ratio (OR); confidence interval at 95% (CI 95%) was calculated; Mantel-Haenzel's Chi(2) was applied. A total of 113 cases and 113 matched controls were studied. There were 37 males and 76 females and the mean age was 69 +/- 15 years in each group. The prevalence of IBS in cases was 16.9%vs 1.8% in controls. The risk of IBS was 11.05 times higher among cases than in controls (P < 0.001); CI 95%: (2.45-49.74). A total of 87 pairs with complete data were used for OR calculation. The risk of IBS was 7.5 times higher in cases than in controls (P = 0.002); CI 95%: (1.72-32.80). This case-control study shows that IBS is more frequent in IC patients than in controls.

Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine

BACKGROUND

Mallory-Weiss syndrome (MWS) with active bleeding at endoscopy may require endoscopic haemostasis the modalities of which are not well-defined.

AIM

To compare the efficacy of endoscopic band ligation vs. hemoclip plus epinephrine (adrenaline) in bleeding MWS.

METHODS

From 2001 to 2008, 218 consecutive patients with a MWS at endoscopy were hospitalized in our Gastrointestinal Bleeding Unit. In 56 patients (26%), an endoscopic haemostasis was required because of active bleeding. Band ligation was performed in 29 patients (Banding group), while hemoclip application plus epinephrine injection was performed in 27 patients (H&E group). Treatment efficacy and early recurrent bleeding were retrospectively compared between the two groups.

RESULTS

Primary endoscopic haemostasis was achieved in all patients. Recurrent bleeding occurred in 0% in Banding group vs. 18% in H&E group (P = 0.02). The use of hemoclips plus epinephrine (OR = 3; 95% CI = 1.15-15.8) and active bleeding at endoscopy (OR = 1.9; 95% CI = 1.04-5.2) were independent predictive factors of early recurrent bleeding.

CONCLUSIONS

Haemostasis by hemoclips plus epinephrine was an independent predictive factor of rebleeding. This result suggests that band ligation could be the first choice endoscopic treatment for bleeding MWS, but requires further prospective assessment.

Translocation of an intra-uterine contraceptive device with sigmoid penetration through an endometriosic nodule

The intra-uterine device (IUD) is the most common existing reversible contraception. Uterine perforation occurs in 0.6 to 3.4 per 1000 insertions. We describe the first report of IUD translocation and subsequent penetration of the sigmoid through an endometriosic nodule. A 44-year-old gravida 2 para 2 woman consulted for rectal bleeding and melena. Rectosigmoidoscopy revealed ischemic colitis secondary to the use of NSAIDs, which explained the bleeding, but also sigmoid perforation from part of an intra-uterine device. This was discovered by chance. Perforation had occurred though an endometriosic nodule.

Results of 24-h manometric recording of colonic motor activity with endoluminal instillation of bisacodyl in patients with severe chronic slow transit constipation

The aims of this study were to assess the prevalence of manometric colonic abnormalities and to evaluate the motor effect of intraluminal bisacodyl in a cohort of refractory constipated patients. Twenty-four hour colonic motility recordings were performed in 40 patients referred for a severe intractable chronic constipation. At the end of each recording session the motor effects of the endoluminal instillation of 10 mg bisacodyl were assessed. These patients were compared with 20 healthy subjects. The number of high-amplitude propagating contractions (HAPC) was significantly decreased in patients with slow transit constipation (12 +/- 11.6 vs 1 +/- 8.6, P < 0.001). Based on manometric patterns four groups of patients were isolated. Ten patients had no spontaneous HAPC, no food-induced colonic motor response and significantly lower colonic activity in transverse colon (374 +/- 1220 vs 3249 +/- 3458, P < 0.05). Five patients had significantly increased sigmoid segmental motility (20298 +/- 6364 vs 88780 +/- 3643, P < 0.001) and eight patients had significantly lower number of HAPC without other manometric abnormalities while 17 patients had normal colonic motility recordings. Endoluminal bisacodyl was able to induce HAPCs in all groups of patients. Patients with severe slow transit refractory constipation represented a heterogeneous group and endoluminal bisacodyl was able to promote a propagated motor activity in a majority of patients even in those suspected of having an inert colon.

Acute laryngeal paralysis induced by the migration of a totally implantable venous access device's catheter tip

The authors report a case of acute vagus nerve paralysis that appeared during a course of chemotherapy. The drugs had been administered through a totally implantable venous access device (TIVAD), whose catheter tip had migrated into the right internal jugular vein (IJV) and was surrounded by a complete venous thrombosis. The supposed aetiology of this paralysis was a leakage of the cytotoxic drug (5-fluorouracil) from the vessel wall into the surrounding carotid space, because of the stagnation of the chemotherapeutic agent above the thrombosis. Four months after cessation of chemotherapy, the laryngeal paralysis was still evident.

Spontaneous passage of a dislocated esophageal metal stent: report of two cases

Delayed transpyloric impaction is a very rare complication of esophageal metallic stent placement. Authors report different endoscopic removal techniques, but none of these has been validated yet because of their variable success, time-consuming nature, and risk of perforation and hemorrhage. We report that a "wait-and-see" approach is a safe and effective policy in patients with permeable transpyloric impacted esophageal stents.

Endoscopic sinus surgery for sinonasal haemangiopericytomas

Haemangiopericytomas are rare peri-vascular tumours with variable malignant potential. The nasal cavity and the paranasal sinuses are most often involved in the head and neck. Five cases of haemangiopericytomas treated by a strict endonasal endoscopic approach are presented. Bleeding and nasal obstruction are the most frequent symptoms. Computed tomography (CT) scan and magnetic resonance imaging (MRI) allowed pre-operative assessment. Angiography with embolization was needed in two of the five cases. None of our patients presented with malignant histology. Our five cases were operated on, and a total tumour excision was performed through the endoscopic endonasal approach. We had one recurrence with a mean follow-up of 4.5 years. We suggest that when the tumour is purely intranasal or strictly located in the ethmoid or sphenoid sinus, it can be removed via an endonasal approach under endoscopic guidance in experienced hands.

Low levels of gastric mucosal glutathione during upper gastric bleeding associated with the use of nonsteroidal anti-inflammatory drugs

OBJECTIVES

To investigate the glutathione concentrations in gastric mucosa from patients with acute gastric bleeding related to nonsteroidal anti-inflammatory drugs (NSAIDs), and to test the influence of nutritional status on mucosal glutathione. Glutathione protects the gastrointestinal mucosa against reactive oxygen species, and glutathione content in various tissues may be depleted during malnutrition.

METHODS

Endoscopic biopsies were obtained from 39 patients. Eighteen of these (9 well-nourished, 9 malnourished) presented with gastric bleeding ulcers related to NSAIDs. Twenty-one other patients (12 well-nourished, 9 malnourished) underwent normal routine diagnostic endoscopy and served as controls. Malnutrition was defined as a loss of over 10% of normal body weight and/or plasma albumin levels below 30 g/l. Gastric biopsies were taken from the fundus and antrum (controls) and from the region of the ulcer (patients with acute bleeding) and frozen quickly until glutathione analysis by high-performance liquid chromatography (HPLC) coulometric detection. Results were expressed as nmol/mg wet tissue.

RESULTS

Gastric mucosal glutathione levels were significantly (P < 0.05) lower in both the antrum (0.81 +/- 0.34 v. 1.41 +/- 0.88 nmol/mg tissue) and the fundus (1.04 +/- 0.54 v. 1.43 +/- 0.92 nmol/mg tissue, P < 0.05) in malnourished than in well-nourished control patients. Glutathione mucosal concentrations were decreased significantly in patients with NSAID-induced gastric bleeding compared with control patients (0.38 +/- 0.36 v. 1.12 +/- 0.56 nmol/mg tissue, P < 0.001), and the lowest glutathione levels were observed in malnourished patients (0.28 +/- 0.20 v. 0.48 +/- 0.15 nmol/mg tissue in well-nourished patients, not significant).

CONCLUSION

Malnutrition is associated with low levels of gastric glutathione. This may contribute to the severity and the onset of haemorrhage in NSAID-induced gastric ulcers.

[Value of total thyroidectomy in amiodarone-induced hyperthyroidism]

The potential severity of amiodarone-induced hyperthyroidism, particularly in severe cardiopathy cases, necessitates a regular clinic and biologic thyroid control. The break in amiodarone and a medical treatment (synthetic antithyroid drugs, steroids, perchlorate of potassium) can be ineffective. The authors report the case of a patient with an right ventricle arythmogenic dysplasia, without thyroid history, who came back 3 years after the introducing of amiodarone with major hyperthyroidism. After failure of medical treatment, a total thyroidectomy permitted to quickly stop hyperthyroidism and to early reintroduce amiodarone. Surgery seems to be the radical treatment when hyperthyroidism doesn't respond to the medical treatment and when the cardiopathy requires amiodarone.

Does the supplementation of the formula with fibre increase the risk of gastro-oesophageal reflux during enteral nutrition? A human study

BACKGROUND & AIMS

Fibre-supplements in enteral feeding could increase the risk of gastro-oesophageal reflux (GOR). The aim of this study was to assess in humans the physiological effects of the supplementation of the enteral diet with different types of dietary fibre on gastro-oesophageal reflux episodes, gastric acidity and gastric emptying.

METHODS

pH profiles were compared in 12 healthy volunteers between three different formula (500 kcal, 250 mL x h-1) delivered in a random order and containing either no fibre, either soy polysaccharide fibre only or mixed fibre from pea and inuline. Enteral diets were instilled through a nasogastric tube. Oesophageal and gastric pH recordings were combined with the ultrasound measurement of gastric antral area during the infusion.

RESULTS

More GOR were observed with a fibre-free diet (median 4, range 1-10) than with a mixed (median 1.5, range 0-5) (P=0.04) or soy polysaccharide fibre (median 1.5, range 0-5) (P=0.04) diet. The median duration of GOR was longer with the mixed fibre (median 3.6, range 1.8-7.2) than with the fibre-free diet (mean 1.8 min, range 1-3.6) (P<0.05). The number of GOR episodes lasting more than 5 min, the duration of the longest GOR and the percent of time under pH 4 were not significantly different with the three diets. The intragastric pH profile and the ultrasound antral area were not different with all three diets.

CONCLUSIONS

Addition of fibre to the enteral formula had limited effects on the onset of GOR episodes. It decreased the number of GOR but increased their duration. These effect were more pronounced with the formula containing soluble fibre. At variance, the addition of fibre had no significant effect on gastric emptying and gastric acid secretion.

Chronic hepatitis C with normal or abnormal aminotransferase levels: is it the same entity?

OBJECTIVE

The features of hepatitis C virus (HCV) infection with persistently normal serum alanine aminotransferase (ALT) activity levels are not well defined. This study evaluated the characteristics of HCV infection according to the presence or absence of elevated ALT.

METHODS

Demographic data, liver histology and HCV genotype were studied in a group of 80 HCV-RNA-positive subjects with persistently normal ALT (PNALT) (group 1), and compared with a second group of 455 HCV-RNA-positive patients with elevated ALT (group 2). The annual progression of liver fibrosis was also calculated.

RESULTS

A higher proportion of women was found in group 1:64% vs 42% in group 2 (P< 0.0002). The HCV genotype 1 was less frequent in group 1:49% vs 60% in group 2 and genotype 2 was more frequent: 16% in group 1 vs 4% in group 2 (P< 0.002). Cirrhosis was less frequent in group 1 (4% vs 13% in group 2 (P< 0.0001)). Normal liver was more frequent in group 1:9% vs 1% in group 2 (P< 0.0001). The Knodell score was significantly different between the two groups: 3.2 +/- 0.27 vs 7.15 +/- 0.22 (P< 0.0001). The progression of liver fibrosis was lower in group 1: 0.053 +/- 0.14 units/year vs 0.13 +/- 0.24 in group 2 (P < 0.007).

CONCLUSION

HCV infection with PNALT is associated with less severe histological liver disease and a lower fibrosis progression rate. This suggests that the natural history of HCV infection in these patients is different from that in patients with abnormal ALT.

[Expandable metal stents in palliative treatment of malignant colorectal stricture. A report of 17 consecutive patients]

OBJECTIVE

Several endoscopic procedures have been used to avoid a colostomy in palliative treatment of occlusive colorectal cancer. The aim of this study was to evaluate in intent to treat the long term effectiveness and safety of self-expanding metal stents as a palliative treatment in patients with neoplastic colonic obstruction.

PATIENTS AND METHODS

From December 1997 to June 2000, seventeen patients were treated with 21 colonic stents. Sites of obstruction were high rectum in 3, sigmoid in 11 and left colon in 3.

RESULTS

Stent placement was successful in 16/17 patients (94%). Relief of bowel obstruction occurred in 13 patients (74%) in the first 48 hours. Expandable metal stent achieved an effective bowel transit until death in 9 of the 17 patients (53%). Clinical complications occurred in 6 patients (35%): 2 perforations, 2 migrations, 1 rectal bleeding and 1 dislocation of the stent. Subsequent colostomy was done in 5 patients.

CONCLUSION

Colonic stenting is an alternative palliative treatment in malignant colorectal stricture. However, morbidity and need for subsequent colostomy should be taken into account.

[Intrahepatic portocaval shunt: review of the literature, apropos of 1 case]

We report a case of portal-hepatic shunt which was detected fortuitously by ultrasonography in a 66-year-old patient. This abnormality, mainly described in cirrhotic liver and rarely in healthy liver, is usually revealed by hepatic encephalopathy or glycoregulation disorders. We propose a diagnostic and therapeutic approach based on a review of the literature.

Management of sinonasal hemangiopericytomas

The purpose of the present study is to report four cases of sinonasal hemangiopericytoma (HP) diagnosed and treated in our department between 1987 and 1998. The pretreatment findings and the treatment are described and discussed in the light of the literature. HP are unusual vascular tumors, featuring pericytes distributed around normal vascular channels. Two of these four cases were located in the nasal cavity and the other two were located in the maxillary sinus. Inside the nasal cavity, HP presented as a protruding reddish-gray mass with marked bleeding on contact. Electron microscopy and immunohistochemical techniques are essential for diagnosis and to distinguish HP from other sarcomatous tumors. Preoperative assessment included routine CT, MRI, arteriography and selective embolization. These tumors must be treated surgically with complete excision. An endonasal approach was performed in two cases of intranasal HP, while a combined external-endonasal approach was required for the other two cases of HP.

[Reflections on percutaneous tracheotomy. Regarding a retrospective study of 106 cases with major burns]

About ten years ago, a new technique for tracheotomy was invented in the United States and has tended to replace the surgical technique in intensive care units. Percutaneous tracheotomy is performed by the intensive care unit physician working in the unit at the patient's bedside. Progressive expansion seems to be the method of choice. Physicians at the Center for burn victims at the Percy Army Hospital have used this technique since 1994. We performed a retrospective study of 106 cases, between 1994 and 1998, and reviewed the international literature. Percutaneous tracheotomies were performed via a vertical cutaneous discharge incision and appeared to be particularly interesting for patients with major burns who are difficult to transport and risk secondary infections. Three early and serious complications were observed, emphasizing the need of a peroperative endotracheal fiberoptic endoscopic control. Three tracheal stenoses were observed: however respiratory tract burns had occurred all three of these patients. In the literature, most of which has been written by intensive care physicians, it is rather surprising to note the enthusiasm for percutaneous tracheotomy based on the high risk of complications of the surgical technique. Moreover, possible late after effects of percutaneous tracheotomy remain unknown as few survivors have been seen again late after use of this recent technique.

[Therapeutic sera and immunoglobulins available in France as of 1 January 1998]

The antisera and immunoglobulins of therapeutical use, commercially available in France on January 1, 1998, have been listed. For each preparation the pharmaceutical form and status, the way of administration and preservation, the dosages, the indications, the side effects and the contraindications are detailed.