Infection risk reduction with povidone-iodine rectal disinfection prior to transrectal prostate biopsy: an updated systematic review and meta-analysis

BACKGROUND

To prevent infectious complications after transrectal ultrasound-guided prostate biopsy (TRUS-PB), some studies have investigated the efficacy of rectal disinfection using povidone-iodine (PI) and antibiotic prophylaxis (AP).

OBJECTIVE

To summarize available data and compare the efficacy of rectal disinfection using PI with non-PI methods prior to TRUS-PB.

EVIDENCE ACQUISITION

Three databases were queried through November 2023 for randomized controlled trials (RCTs) analyzing patients who underwent TRUS-PB. We compared the effectiveness of rectal disinfection between PI groups and non-PI groups with or without AP. The primary outcomes of interest were the rates of overall infectious complications, fever, and sepsis. Subgroups analyses were conducted to assess the differential outcomes in patients using fluoroquinolone groups compared to those using other antibiotics groups.

EVIDENCE SYNTHESIS

We included ten RCTs in the meta-analyses. The overall rates of infectious complications were significantly lower when rectal disinfection with PI was performed (RR 0.56, 95% CI 0.42-0.74, p < 0.001). Compared to AP monotherapy, the combination of AP and PI was associated with significantly lower risk of infectious complications (RR 0.54, 95% CI 0.40-0.73, p < 0.001) and fever (RR 0.47, 95% CI 0.30-0.75, p = 0.001), but not with sepsis (RR 0.49, 95% CI 0.23-1.04, p = 0.06). The use of fluoroquinolone antibiotics was associated with a lower risk of infectious complications and fever compared to non-FQ antibiotics.

CONCLUSION

Rectal disinfection with PI significantly reduces the rates of infectious complications and fever in patients undergoing TRUS-PB. However, this approach does not show a significant impact on reducing the rate of sepsis following the procedure.

Magnetic Resonance Imaging in Prostate Cancer Screening: A Systematic Review and Meta-Analysis

Importance

Prostate magnetic resonance imaging (MRI) is increasingly integrated within the prostate cancer (PCa) early detection pathway.

Objective

To systematically evaluate the existing evidence regarding screening pathways incorporating MRI with targeted biopsy and assess their diagnostic value compared with prostate-specific antigen (PSA)-based screening with systematic biopsy strategies.

Data Sources

PubMed/MEDLINE, Embase, Cochrane/Central, Scopus, and Web of Science (through May 2023).

Study Selection

Randomized clinical trials and prospective cohort studies were eligible if they reported data on the diagnostic utility of prostate MRI in the setting of PCa screening.

Data Extraction

Number of screened individuals, biopsy indications, biopsies performed, clinically significant PCa (csPCa) defined as International Society of Urological Pathology (ISUP) grade 2 or higher, and insignificant (ISUP1) PCas detected were extracted.

Main Outcomes and Measures

The primary outcome was csPCa detection rate. Secondary outcomes included clinical insignificant PCa detection rate, biopsy indication rates, and the positive predictive value for the detection of csPCa.

Data Synthesis

The generalized mixed-effect approach with pooled odds ratios (ORs) and random-effect models was used to compare the MRI-based and PSA-only screening strategies. Separate analyses were performed based on the timing of MRI (primary/sequential after a PSA test) and cutoff (Prostate Imaging Reporting and Data System [PI-RADS] score ≥3 or ≥4) for biopsy indication.

Results

Data were synthesized from 80 114 men from 12 studies. Compared with standard PSA-based screening, the MRI pathway (sequential screening, PI-RADS score ≥3 cutoff for biopsy) was associated with higher odds of csPCa when tests results were positive (OR, 4.15; 95% CI, 2.93-5.88; P ≤ .001), decreased odds of biopsies (OR, 0.28; 95% CI, 0.22-0.36; P ≤ .001), and insignificant cancers detected (OR, 0.34; 95% CI, 0.23-0.49; P = .002) without significant differences in the detection of csPCa (OR, 1.02; 95% CI, 0.75-1.37; P = .86). Implementing a PI-RADS score of 4 or greater threshold for biopsy selection was associated with a further reduction in the odds of detecting insignificant PCa (OR, 0.23; 95% CI, 0.05-0.97; P = .048) and biopsies performed (OR, 0.19; 95% CI, 0.09-0.38; P = .01) without differences in csPCa detection (OR, 0.85; 95% CI, 0.49-1.45; P = .22).

Conclusion and relevance

The results of this systematic review and meta-analysis suggest that integrating MRI in PCa screening pathways is associated with a reduced number of unnecessary biopsies and overdiagnosis of insignificant PCa while maintaining csPCa detection as compared with PSA-only screening.

A Systematic Review and Meta-analysis of the Impact of Local Therapies on Local Event Suppression in Metastatic Hormone-sensitive Prostate Cancer

CONTEXT

It remains unclear to what extent the therapy of the primary local tumor, such as radical prostatectomy (RP) and radiation therapy (RT), improves overall survival in patients with low-volume metastatic hormone-sensitive prostate cancer (mHSPC). However, data suggest a benefit of these therapies in preventing local events secondary to local tumor progression.

OBJECTIVE

To evaluate the efficacy of adding local therapy (RP or RT) to systemic therapies, including androgen deprivation therapy, docetaxel, and/or androgen receptor axis-targeted agents, in preventing local events in mHSPC patients compared with systemic therapy alone (ie, without RT of the prostate or RP).

EVIDENCE ACQUISITION

Three databases and meeting abstracts were queried in November 2023 for studies analyzing mHSPC patients treated with local therapy. The primary outcome of interest was the prevention of overall local events (urinary tract infection, urinary tract obstruction, and gross hematuria) due to local disease progression. Subgroup analyses were conducted to assess the differential outcomes according to the type of local therapy (RP or RT).

EVIDENCE SYNTHESIS

Overall, six studies, comprising two randomized controlled trials, were included for a systematic review and meta-analysis. The overall incidence of local events was significantly lower in the local treatment plus systemic therapy group than in the systemic therapy only groups (relative risk [RR]: 0.50, 95% confidence interval [CI]: 0.28-0.88, p = 0.016). RP significantly reduced the incidence of overall local events (RR: 0.24, 95% CI: 0.11-0.52) and that of local events requiring surgical intervention (RR: 0.08, 95% CI: 0.03-0.25). Although there was no statistically significant difference between the RT plus systemic therapy and systemic therapy only groups in terms of overall local events, the incidence of local events requiring surgical intervention was significantly lower in the RT plus systemic therapy group (RR: 0.70, 95% CI: 0.49-0.99); local events requiring surgical intervention of the upper urinary tract was significantly lower in local treatment groups (RR: 0.60, 95% CI: 0.37-0.98, p = 0.04). However, a subgroup analysis revealed that neither RP nor RT significantly impacted the prevention of local events requiring surgical intervention of the upper urinary tract.

CONCLUSIONS

In some patients with mHSPC, RP or RT of primary tumor seems to reduce the incidence of local progression and events requiring surgical intervention. Identifying which patients are most likely to benefit from local therapy, and at what time point (eg, after response of metastases), will be necessary to set up a study assessing the risk, benefits, and alternatives to therapy of the primary tumor in the mHSPC setting.

PATIENT SUMMARY

Our study suggests that local therapy of the prostate, such as radical prostatectomy or radiotherapy, in patients with metastatic hormone-sensitive prostate cancer can prevent local events, such as urinary obstruction and gross hematuria.

PARP inhibitor era in ovarian cancer treatment: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Ovarian cancer is the eighth leading cause of cancer-related death among women, characterized by late diagnosis and a high relapse rate. In randomized controlled trials, we aimed to evaluate the efficacy and safety of PARP inhibitors (PARPi) in treating advanced ovarian cancer.

METHODS

This review was registered on PROSPERO (CRD42021283150), included all phase II and phase III randomized controlled trials (RCTs) assessing the effect of PARPi on ovarian cancer until the 13th of April, 2022. The main outcomes were progression- free survival (PFS), overall survival (OS), and adverse events (AEs). Pooled hazard ratios (HRs), and risk ratios (RRs) were calculated with 95% confidence intervals (95% CI). The random-effects model was applied in all analyses.

RESULTS

In the meta-analysis, 16 eligible RCTs were included, with a total of 5,815 patients. In recurrent ovarian cancer, PARPi maintenance therapy showed a significant PFS benefit over placebo in the total population (HR 0.34, CI 0.29-0.40), BRCA mutant (HR 0.24, CI 0.18-0.31), germline BRCA mutant (HR 0.23, CI 0.18-0.30), and BRCA wild-type cases (HR 0.50, CI 0.39-0.65). PARPi monotherapy also improved PFS (HR 0.62, CI 0.51-0.76) compared with chemotherapy in BRCAm patients with recurrent ovarian cancer. The use of PARPi maintenance therapy resulted in an improvement in PFS over placebo in newly-diagnosed cancers in the overall population (HR 0.46, CI 0.30-0.71) and the BRCAm population (HR 0.36, CI 0.29-0.44). Although the risk of severe AEs was increased by PARPi therapy compared to placebo in most settings investigated, these side effects were controllable with dose modification, and treatment discontinuation was required in the minority of cases.

CONCLUSIONS

PARPis are an effective therapeutic option for newly-diagnosed and recurrent ovarian cancer. Despite a minor increase in the frequency of serious adverse effects, they are generally well tolerated.

Therapeutic sensitivity to standard treatments in BRCA positive metastatic castration-resistant prostate cancer patients-a systematic review and meta-analysis

BACKGROUND

Recent oncology guidelines recommend BRCA1/2 testing for a wide range of prostate cancer (PCa) patients. In addition, PARP inhibitors are available for mutation-positive metastatic castration-resistant PCa (mCRPC) patients following prior treatment with abiraterone, enzalutamide or docetaxel. However, the question of which of these standard treatments is the most effective for BRCA1/2 positive mCRPC patients remains to be answered. The aim of this meta-analysis was to assess the efficacy of abiraterone, enzalutamide and docetaxel in BRCA1/2 mutation-positive mCRPC patients in terms of PSA-response (PSA50), progression-free survival (PFS) and overall survival (OS).

METHODS

As no interventional trials are available on this topic, we performed the data synthesis of BRCA1/2 positive mCRPC patients by using both proportional and individual patient data. For PSA50 evaluation, we pooled event rates with 95% confidence intervals (CI), while for time-to-event (PFS, OS) analyses we used individual patient data with random effect Cox regression calculations.

RESULTS

Our meta-analysis included 16 eligible studies with 348 BRCA1/2 positive mCRPC patients. In the first treatment line, response rates for abiraterone, enzalutamide and docetaxel were 52% (CI: 25-79%), 64% (CI: 43-80%) and 55% (CI: 36-73%), respectively. Analyses of individual patient data revealed a PFS (HR: 0.47, CI: 0.26-0.83, p = 0.010) but no OS (HR: 1.41, CI: 0.82-2.42, p = 0.210) benefit for enzalutamide compared to abiraterone-treated patients.

CONCLUSIONS

Our PSA50 analyses revealed that all the three first-line treatments have therapeutic effect in BRCA1/2 positive mCRPC; although, based on the results of PSA50 and PFS analyses, BRCA positive mCRPC patients might better respond to enzalutamide treatment. However, molecular marker-driven interventional studies directly comparing these agents are crucial for providing higher-level evidence.

Efficacy of immune checkpoint inhibitor therapy for advanced urothelial carcinoma in real-life clinical practice: results of a multicentric, retrospective study

Clinical trials revealed significant antitumor activity for immune checkpoint inhibitors (ICI) in metastatic urothelial carcinoma (mUC). Due to their strict eligibility criteria, clinical trials include selected patient cohorts, and thus do not necessarily represent real-world population outcomes. In this multicentric, retrospective study, we investigated real-world data to assess the effectiveness of pembrolizumab and atezolizumab and to evaluate the prognostic value of routinely available clinicopathological and laboratory parameters. Clinical and follow-up data from mUC patients who received ICIs (01/2017-12/2021) were evaluated. Overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and duration of response (DOR) were used as endpoints. Patients' (n = 210, n = 76 atezolizumab and 134 pembrolizumab) median OS and PFS were 13.6 and 5.9 months, respectively. Impaired ECOG-PS, the presence of visceral, liver or bone metastases, and hemoglobin levels were independently associated with poor OS and DCR. Furthermore, Bellmunt risk factors and the enhanced Bellmunt-CRP score were shown to be prognostic for OS, PFS and DCR. In conclusion, ICIs are effective treatments for a broad range of mUC patients. Our results confirmed the prognostic value of numerous risk factors and showed that Bellmunt risk scores can further be improved when adding CRP to the model.

Poly (ADP-ribose) Polymerase Inhibitors Have Comparable Efficacy with Platinum Chemotherapy in Patients with BRCA-positive Metastatic Castration-resistant Prostate Cancer. A Systematic Review and Meta-analysis

CONTEXT

Testing for mutations in Breast Cancer Gene 1/2 (BRCA) has emerged as a novel decision-making tool for clinicians. Patients with metastatic castration-resistant prostate cancer (mCRPC) harboring pathogenic BRCA mutations can benefit from poly (ADP-ribose) polymerase inhibitor (PARPi) and platinum treatments, whereas the impact of the mutation on sensitivity to cabazitaxel and prostate-specific membrane antigen (PSMA)-ligand therapy is currently unknown.

OBJECTIVE

To assess the efficacy of PARPi, platinum, cabazitaxel, and PSMA-ligand therapies in BRCA-positive mCRPC.

EVIDENCE ACQUISITION

Databases were queried in February 2022. We performed data synthesis by using both proportional and individual patient data. For prostate-specific antigen (PSA) response rate (≥50% decrease from baseline [PSA50]) evaluation, we pooled event rates with 95% confidence intervals (CIs). Progression-free (PFS) and overall (OS) survival analyses with individual patient data were performed with the mixed-effect Cox proportional hazard model and single-arm random-effect analysis, providing pooled medians.

EVIDENCE SYNTHESIS

We included 23 eligible studies with 901 BRCA-positive mCRPC patients. PSA50 response rates for PARPi and platinum were 69% (CI: 53-82%), and 74% (CI: 49-90%), respectively. Analyses of OS data showed no difference between PARPi and platinum treatments (hazard ratio: 0.86; CI: 0.49-1.52; p = 0.6). The single-arm OS and PFS analyses revealed similarities among different PARPis; pooled PFS and OS medians were 9.7 mo (CI: 8.1-12.5) and 17.4 mo (CI: 12.7-20.1), respectively.

CONCLUSIONS

Our data revealed that different PARPis were similarly effective in terms of PFS and OS. Moreover, we found that PARPi and platinum therapy were comparable in terms of PSA50 response rate and OS, highlighting that platinum is a valid treatment option for BRCA-positive mCRPC patients. However, prospective interventional studies comparing these agents are essential to provide a higher level of evidence.

PATIENT SUMMARY

In this report, we found that different poly (ADP-ribose) polymerase inhibitors had similar efficacy, and platinum was a valid treatment option in BRCA-positive metastatic castration-resistant prostate cancer patients.

[Current therapeutic and familial implications of the genetic background of prostate cancer]

Genetic testing for prostate cancer (PC) is becoming more widely used in the clinical routine, primarily due to the introduction of PARP inhibitors targeting genetically affected patients in their BRCA1/2 and other homologous recombination repair (HRR) genes. Simultaneously, the number of available therapies that are specifically targeting genetically defined PC subgroups is steadily increasing. As a result, the selection of treatment for PC patients is likely to require testing of multiple genes to enable more specific treatment sequences that consider the genetic characteristics of the tumor. Some of the mutations discovered by genetic testing may be hereditary, necessitating the use of germline testing from normal tissue, which is only permitted within the framework of clinical counseling. This change in PC care requires the collaboration by multiple specialists, including experts in molecular pathology, bioinformatics, biology, and genetic counseling. In this review, we aim to provide an overview on the currently relevant genetic alterations in PC for therapeutic purposes and their implications for familial testing.

Comparative proteome analysis identified CD44 as a possible serum marker for docetaxel resistance in castration-resistant prostate cancer

Baseline or acquired resistance to docetaxel (DOC) represents a significant risk for patients with metastatic prostate cancer (PC). In the last years, novel therapy regimens have been approved providing reasonable alternatives for DOC‐resistant patients making prediction of DOC resistance of great clinical importance. We aimed to identify serum biomarkers, which are able to select patients who will not benefit from DOC treatment. DOC‐resistant PC3‐DR and DU145‐DR sublines and their sensitive parental cell lines (DU145, PC3) were comparatively analyzed using liquid chromatography‐coupled tandem mass spectrometry (LC‐MS/MS). Results were filtered using bioinformatics approaches to identify promising serum biomarkers. Serum levels of five proteins were determined in serum samples of 66 DOC‐treated metastatic castration‐resistant PC patients (mCRPC) using ELISA. Results were correlated with clinicopathological and survival data. CD44 was subjected to further functional cell culture analyses. We found at least 177 two‐fold significantly overexpressed proteins in DOC‐resistant cell lines. Our bioinformatics method suggested 11/177 proteins to be secreted into the serum. We determined serum levels of five (CD44, MET, GSN, IL13RA2 and LNPEP) proteins in serum samples of DOC‐treated patients and found high CD44 serum levels to be independently associated with poor overall survival (p = 0.001). In accordance, silencing of CD44 in DU145‐DR cells resulted in re‐sensitization to DOC. In conclusion, high serum CD44 levels may help identify DOC‐resistant patients and may thereby help optimize clinical decision‐making regarding type and timing of therapy for mCRPC patients. In addition, our in vitro results imply the possible functional involvement of CD44 in DOC resistance.

Efficacy of carboplatin chemotherapy in a metastatic, castration-resistant BRCA2 mutation positive prostate cancer patient

Összefoglaló. A sérült BRCA1/2 gént hordozó prosztatadaganatok klinikai szempontból elkülönülő, agresszív altípust képviselnek. Ugyanakkor a BRCA1/2 gén sérülése a DNS-támadáspontú kemoterápiákkal szemben érzékennyé teszi a daganatot, ami terápiás szempontból kihasználható. A platinaalapú kemoterápia hatékonysága prosztatarákban klinikai vizsgálatokkal nincs alátámasztva, ezért annak alkalmazására igen ritkán kerül sor. Közleményünkben egy előrehaladott stádiumú, agresszív prosztata adenocarcinomával diagnosztizált beteg esetét mutatjuk be, akinél a BRCA2-gén patogén mutációját találtuk, és akinél az előzőleg alkalmazott androgénmegvonásos, valamint docetaxelkezelések sikertelensége miatt karboplatinkezelést alkalmaztunk - ez a beteg állapotának, valamint radiológiai és biokémiai paramétereinek látványos javulásához vezetett. Ez az eset rámutat a DNS-hiba-javító mechanizmusban szerepet játszó gének terápiás szempontból történő felhasználásának potenciális előnyeire prosztatarákban. Orv Hetil. 2021; 162(25): 1004-1008. Summary. BRCA1/2 deficient prostate cancers represent a clinically distinct aggressive subtype. However, the presence of BRCA1/2 alterations enhance the sensitivity to platinum-based chemotherapies. The efficacy of platinum-based chemotherapies in prostate cancer has not been proven in prospective clinical studies and therefore these treatments are rarely used in prostate adenocarcinomas. Here we present a case of BRCA2 mutant prostate cancer, which was diagnosed at a metastatic stage and showed no or only little response to androgen deprivation and docetaxel therapies. Therefore, we started carboplatin chemotherapy which resulted in an exceptional response regarding biochemical, radiographic parameters accompanied by significant improvement of patients' physical condition. This case underlines the potential therapeutic benefits of testing for genes involved in the DNA repair mechanism. Orv Hetil. 2021; 162(25): 1004-1008.

The prognostic value of serum MMP-7 levels in prostate cancer patients who received docetaxel, abiraterone, or enzalutamide therapy

OBJECTIVES

The rapidly changing treatment landscape in metastatic castration-resistant prostate cancer (mCRPC) calls for biomarkers to guide treatment decisions. We recently identified MMP-7 as a potential serum marker for the prediction of response and survival in mCRPC patients who received docetaxel (DOC) chemotherapy. Here, we aimed to test this finding in an independent patient cohort and in addition to explore the prognostic potential of serum MMP-7 in abiraterone (ABI) or enzalutamide (ENZA) treated patients.

METHODS AND MATERIALS

MMP-7 levels were measured in 836 serum samples from 320 mCRPC patients collected before and during DOC (n = 95), ABI (n = 140), or ENZA (n = 85) treatment by using the ELISA method. Results were correlated with clinical and follow-up data.

RESULTS

MMP-7 baseline levels were similar between the 3 treatment groups. In the ABI and ENZA cohorts, baseline MMP-7 levels were lower in patients with prior radical prostatectomy (P = 0.058 and P = 0.041, respectively). Baseline MMP-7 levels above the median were associated with shorter overall survival for the DOC (P = 0.001) and ENZA (P = 0.006) cohorts. Multivariable analyses in the DOC and ENZA cohorts revealed that high pretreatment MMP-7 level is an independent risk factor for patients' survival. In addition, in DOC-treated patients with high baseline MMP-7 level, marker decrease at the third DOC cycle was associated with improved survival. Patients with high baseline MMP-7 levels had better survival when treated with ABI compared to DOC or ENZA.

CONCLUSIONS

We confirmed the prognostic value of pretreatment MMP-7 serum level and its changes as independent predictors of survival in DOC-treated mCRPC patients. In addition, high MMP-7 was a negative predictor in ENZA-treated but not in ABI-treated patients. These results warrant further research to confirm the predictive value of serum MMP-7 and to explore the potential mechanistic involvement of MMP-7 in DOC and ENZA resistance of mCRPC patients.

Comprehensive analysis of serum chromogranin A and neuron-specific enolase levels in localized and castration-resistant prostate cancer

OBJECTIVES

To assess chromogranin A (CGA) and neuron-specific enolase (NSE) levels and changes in these at different stages of prostatic adenocarcinoma (PCA).

METHODS

Overall, 1095 serum samples from 395 patients, divided into three treatment groups, were analysed; the radical prostatectomy (RP) cohort (n = 157) included patients with clinically localized PCA, while the docetaxel (DOC) and the abiraterone (ABI)/enzalutamide (ENZA) cohorts included 95 and 143 patients, respectively, with metastatic castration-resistant prostate cancer. CGA, NSE and total PSA levels were measured using the KRYPTOR method.

RESULTS

Baseline CGA and NSE levels were higher in castration-resistant (DOC and ABI/ENZA cohorts) than in hormone-naïve, clinically localized PCA (P < 0.001). High baseline CGA levels were independently associated with poor overall survival in both the DOC and the ABI/ENZA cohorts, with a stronger association in the ABI/ENZA cohort. In the ABI/ENZA cohort, a > 50% CGA increase at 3 months was associated with poor survival, especially in patients with high baseline CGA levels.

CONCLUSIONS

The two- to threefold higher neuroendocrine marker levels in castration-resistant compared to hormone-naïve PCA support the presence of neuroendocrine transdifferentiation under androgen deprivation therapy. Our results showed patients with high baseline CGA levels who experienced a further CGA increase during ABI and ENZA treatment had the poorest prognosis. Serum CGA levels could help in tailoring and monitoring therapy in advanced PCA.

Carrageenan nasal spray in virus confirmed common cold: individual patient data analysis of two randomized controlled trials

Background: Clinical trials applying iota-carrageenan nasal spray have previously shown to reduce duration of virus-confirmed common cold. The present study pooled data of two similar clinical trials to provide further evidence for the antiviral effectiveness of carrageenan. Methods: Individual patient data were analyzed from two randomized double blind placebo controlled trials assessing the therapeutic effectiveness of carrageenan nasal spray in acute common cold. Patients with virus-confirmed common cold (n = 254, verum 126, placebo 128) were included and the following parameters were appraised: duration of disease, number of patients with relapses, number of respiratory viruses and viral titers at inclusion (visit 1) compared to days 3–5 (visit 2). Results: Carrageenan treated patients showed a significant reduction in duration of disease of almost 2 days (p < 0.05) as well as significantly fewer relapses during 21 days of observation period (p < 0.05). The virus clearance between visit 1 and visit 2 was significantly more pronounced in the carrageenan group (p < 0.05). In both studies, virus-confirmed common cold was caused by three main virus subtypes: human rhinovirus (46%), human coronavirus (25%) and influenza A (14%) virus. Carrageenan nasal spray showed significant antiviral efficacy in all three virus subgroups, the highest effectiveness was observed in human corona virus-infected patients. The reduced duration of disease was 3 days (p < 0.01) and the number of relapses was three times less (p < 0.01) in carrageenan treated corona-virus-infected patients compared to control patients. Conclusions: Administration of carrageenan nasal spray in children as well as in adults suffering from virus-confirmed common cold reduced duration of disease, increased viral clearance and reduced relapses of symptoms. Carrageenan nasal spray appeared as an effective treatment of common cold in children and adults. Trial registration: Pooled data from ISRCTN52519535 and ISRCTN80148028

Carrageenan nasal spray in virus confirmed common cold: individual patient data analysis of two randomized controlled trials

Background

Clinical trials applying iota-carrageenan nasal spray have previously shown to reduce duration of virus-confirmed common cold. The present study pooled data of two similar clinical trials to provide further evidence for the antiviral effectiveness of carrageenan.

Methods

Individual patient data were analyzed from two randomized double blind placebo controlled trials assessing the therapeutic effectiveness of carrageenan nasal spray in acute common cold. Patients with virus-confirmed common cold (n = 254, verum 126, placebo 128) were included and the following parameters were appraised: duration of disease, number of patients with relapses, number of respiratory viruses and viral titers at inclusion (visit 1) compared to days 3–5 (visit 2).

Results

Carrageenan treated patients showed a significant reduction in duration of disease of almost 2 days (p < 0.05) as well as significantly fewer relapses during 21 days of observation period (p < 0.05). The virus clearance between visit 1 and visit 2 was significantly more pronounced in the carrageenan group (p < 0.05). In both studies, virus-confirmed common cold was caused by three main virus subtypes: human rhinovirus (46%), human coronavirus (25%) and influenza A (14%) virus. Carrageenan nasal spray showed significant antiviral efficacy in all three virus subgroups, the highest effectiveness was observed in human corona virus-infected patients. The reduced duration of disease was 3 days (p < 0.01) and the number of relapses was three times less (p < 0.01) in carrageenan treated corona-virus-infected patients compared to control patients.

Conclusions

Administration of carrageenan nasal spray in children as well as in adults suffering from virus-confirmed common cold reduced duration of disease, increased viral clearance and reduced relapses of symptoms. Carrageenan nasal spray appeared as an effective treatment of common cold in children and adults.

Trial registration

Pooled data from ISRCTN52519535 and ISRCTN80148028

Exhaled nitric oxide and pulmonary complications after paediatric stem cell transplantation

Pulmonary complications are major causes of morbidity and mortality after haematopoietic stem cell transplantation (HSCT). We hypothesise that elevated exhaled nitric oxide (FeNO) levels early after HSCT in children are predictive for pulmonary complications. The present prospective study included 30 children (age, 4-18 years) before HSCT. FeNO levels were evaluated 10 days before transplant, at day 0, day +28 and day +60 after HSCT. During the follow-up period until day +100, pulmonary complications and lung function were assessed. Before HSCT, the mean FeNO levels were comparable in children with or without post-transplant pulmonary complications. However, they differed at day 0 and day +28 with a mean of 7 (±1.95) and 13 (±3.44) ppb at day 0 and a mean of 13 (±3.44) and 14 (±3.57) ppb at day +28, respectively.

CONCLUSION

Children with pulmonary complications after day +28 have higher mean FeNO levels 28 days after HSCT than children without later pulmonary complications. Therefore, FeNO could be an important diagnostic tool for hyperinflammatory response in bronchial epithelium after paediatric HSCT.

Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD

This consensus statement established under the auspices of the German working group on BM and blood stem cell transplantation (DAG-KBT), the German Society of Hematology and Oncology (DGHO), the Austrian Stem Cell Transplant Working Group, the Swiss Blood Stem Cell Transplantation Group (SBST) and the German-Austrian Pediatric Working Group on SCT (Päd-Ag-KBT) summarizes current evidence for diagnosis, immunosuppressive and supportive therapy to provide practical guidelines for the care and treatment of patients with pulmonary manifestations of chronic GVHD (cGVHD). Pulmonary cGVHD can present with obstructive and/or restrictive changes. Disease severity ranges from subclinical pulmonary function test (PFT) impairment to respiratory insufficiency with bronchiolitis obliterans being the only pulmonary complication currently considered diagnostic of cGVHD. Early diagnosis may improve clinical outcome, and regular post-transplant follow-up PFTs are recommended. Diagnostic work-up includes high-resolution computed tomography, bronchoalveolar lavage and histology. Topical treatment is based on inhalative steroids plus beta-agonists. Early addition of azithromycin is suggested. Systemic first-line treatment consists of corticosteroids plus, if any, continuation of other immunosuppressive therapy. Second-line therapy and beyond includes extracorporeal photopheresis, mammalian target of rapamycin inhibitors, mycophenolate, etanercept, imatinib and TLI, but efficacy is limited. Clinical trials are urgently needed to improve understanding and treatment of this deleterious complication.

Mitral valve endocarditis caused by ulcerative colitis followed by septic embolic occlusion of the superior mesenteric artery

Acute endocarditis is a rare complication of ulcerative colitis. We report on a young woman, who initially presented with fever, elevated inflammatory markers, and symptoms of ulcerative pancolitis but without any cardiac co-morbidity. A few days after total colectomy, the patient complained of acute abdominal pain which led to the suspected diagnosis of mesenteric ischaemia caused by a septic embolus. Transthoracic and transoesophageal echocardiography showed a large vegetation on the anterior leaflet of the mitral valve. The patient was successfully treated by an operative approach including mitral valve replacement.

[The concise history of atrial fibrillation]

The author reviews the history of atrial fibrillation, the most common sustained cardiac arrhythmia. The chaotic irregularity of arterial pulse was clearly acknowledged by most of physicians of the ancient China, Egypt and Greece. William Harvey (1578-1657), who first described the circulatory system appropriately, was probably the first to describe fibrillation of the auricles in animals in 1628. The French "clinical pathologist", Jean Baptist de Sénac (1693-1770) was the first who assumed a correlation between "rebellious palpitation" and stenosis of the mitral valve. Robert Adams (1791-1875) also reported in 1827 the association of irregular pulses and mitral stenosis. The discovery of digitalis leaf in 1785 by William Withering (1741-1799) brought relief to patients with atrial fibrillation and congestive heart failure by reducing the ventricular rate. From an analysis of simultaneously recorded arterial and venous pressure curves, the Scottish Sir James Mackenzie (1853-11925) demonstrated that a presystolic wave cannot be seen during "pulsus irregularis perpetuus", a term very first used by Heinrich Ewald Hering (1866-1948). Arthur Cushny (1866-1926) noted the similarity between pulse curves in clinical "delirium cordis" and those in dogs with atrial fibrillation. The first human ECG depicting atrial fibrillation was published by Willem Einthoven (1860-1927) in 1906. The proof of a direct connection between absolute arrhythmia and atrial fibrillation was established by two Viennese physicians, Carl Julius Rothberger and Heinrich Winterberg in 1909. Sir Thomas Lewis (1881-1945), the father of modem electrocardiography, studied electrophysiological characteristics of atrial fibrillation and has shown that its basic perpetuating mechanism is circus movement of electrical impulse (re-entry). After him, the major discoveries relating to the pathophysiology and clinical features of atrial fibrillation in the 20th century stemmed from Karel Frederick Wenckebach (1864-1940), Gordon Moe (1915-1989), Bernhard Lown (*1921) and Maurits Allessie. Over the past ten years, awareness has increased of transcatheter radiofrequency and cryoablation of non-valvular atrial fibrillation and the battle against formation of intraatrial thrombi for preventing cerebral thromboembolism.

[A concise history of the Wolff-Parkinson-White syndrome]

In a paper entitled Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia (Am Heart J 1930; 5: 685-704), Dr. Louis Wolff (1898-1972), Sir John Parkinson (1885-1976) and Paul Dudley White (1886-1973) described an intricate syndrome. Prior case reports had already pointed out the essentials of this entity, which has borne the eponym (WPW syndrome) since the publication by Levine and Beeson (Am Heart J 1941; 22: 401-409). It was long thought that the first patient with a short PR interval, delta-wave-induced widening of the QRS complex and paroxysmal supraventricular tachycardia (PSVT) was described by Cohn and Fraser in the prestigious cardiological journal edited by Sir Thomas Lewis (1881-1945) in London, UK (Heart 1913/1914; 5: 93-107). Shortly afterwards, Dr János Angyán (1886-1969), a school-founder chairman of medicine (1923-1959) at the University of Pécs, Hungary, also published a clear-cut case of intermittent WPW syndrome in the German periodical Zentralblatt für Herz- und Gefässkrankheiten (1914; 6: 345-349]. In fact, Angyán should be considered the first Hungarian "cardiologist" who dealt steadily with heart diseases and rhythm disturbances. Quite reently, thanks to the activities of Dr Georg von Knorre, Rostock (PACE 2005; 28: 228-230) we have learnt that the earliest documented case of ECGs with ventricular preexcitation and PSVT ("Herzjagen") was published by August Hoffmann (1862-1929) in the 2 Nov 1909 issue of Münchener Medizinische Wochenschrift (56: 2259-2262; Figures 10 and 11). Hoffmann worked as an internist/neurologist and was director of the university hospital in Düsseldorf, Germany. The first successful surgical division of an atrioventricular accessory pathway (bundle of Kent), by Sealy and his coworkers at the Duke University Medical Center in 1967, led to the modern era of curative transcatheter ablation for WPW patients by radiofrequency alternative current or, nowadays, by transvenous cryoablative catheter techniques. Our current knowledge and day-to-day clinical practice is the result of marvelous contributions from numerous dedicated scientists in diverse disciplines in many countries.

[Non-channel drugs to prevent atrial fibrillation]

Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. To terminate or prevent atrial fibrillation, conventional "channel-blocking antiarrhythmics" are generally administered, which directly inhibit current flows through transmembrane sodium, calcium and/or potassium channels that give rise to the atrial action potential. However, prospective, randomized clinical trials have demonstrated that cardiomyocyte ion channel blocking antiarrhythmic drugs have limited long-term-efficacy for preventing recurrences of atrial fibrillation, their safety is far from ideal (because of the high incidence of proarrhythmic and extracardiac side-effects), and do not reduce mortality. Researchers during the last 10 years have revealed that the pathogenetic basis of the recurrence, persistence or permanence of atrial fibrillation is electrical and structural remodelling established by profound alterations in the electrophysiological, contractile and (ultra)structural properties of the myocardium (atrial remodelling). Accordingly, recent interest has shifted from ion channel blockers to the development of drugs that target underlying arrhythmogenic substrates by interference with receptors and specific signal transduction pathways involved in electrical and structural remodelling (non-channel drugs). They include antifibrotic angiotensin-converting enzyme inhibitors, angiotensin II AT1 receptor and aldosterone antagonists, beta-adrenergic blockers, anti-inflammatory statins and glucocorticoids, and a series of new atrioselective antifibrillatory agents that are currently undergoing clinical trials.

[Proarrhythmic (torsadogenic) effects of QT-prolonging non-antiarrhythmic drugs]

The authors review the rapidly expanding knowledge relating to the arrhythmogenic (torsadogenic) effects of non-antiarrhythmic drugs that lengthen ventricular repolarization (i.e. the duration of electrocardiographic QT interval). After outlining the ECG characteristics and electrophysiological mechanism of drug-induced long-QT syndrome and torsades de pointes ventricular tachycardia, they discuss the concept of repolarization reserve and its role in arrhythmogenesis. Information is provided on the cardiac ion channel background of the proarrhythmic action of QT-prolonging non-antiarrhythmic drugs. The authors present pharmacoepidemiological data on the clinical importance and incidence of this peculiar adverse drug reaction that can in certain cases cause sudden arrhythmic death. They draw attention to the predisposing factors of torsades de pointes ventricular tachycardia, and list those groups of drugs and individual agents that have QT-lengthening and torsadogenic side-effects.

[Pathophysiology and clinical management of atrial flatter]

The authors review the current knowledge relating to the pathophysiology and treatment of atrial flutter, the most common supraventricular macroreentrant tachycardia. After an account of the historical and epidemiological data, the atrial tachycardia classification system based on the up-to-date North American + European consensus is presented. The main electrophysiological and electrocardiographic features of right atrial isthmusdependent typical and reverse typical flutter are detailed, as are those of the nonisthmus dependent, atypical forms. The electrophysiological connection between the very frequently coexisting atrial flutter and atrial fibrillation, and also the transitional form (flitter), are discussed. Following the clinical presentation, an account is given of the drug and non-pharmacological therapeutic modalities. It is pointed out that the recently-developed drugs with Vaughan Williams class 3 antiarrhythmic action, which block potassium channels and prolong atrial refractory period, are now primarily used (e.g. ibutilide, dofetilide). Effective means of terminating atrial flutter include transthoracic direct-current cardioversion (pretreated with antiarrhythmic = hybrid therapy) and transoesophageal or intraatrial overdrive pacing. It is stressed that the efficiency of prevention of atrial flutter with the antiarrhythmic drugs currently used even today is poor. Accordingly, the optimum mode of treatment of atrial flutter, which is primarily a method of first choice in special cardiac centres, is curative radiofrequency catheter ablation.

[Non-pharmacologic treatment of atrial fibrillation]

The authors provide an update on non-pharmacological treatment of atrial fibrillation (AF). They emphasize that although antiarrhythmic drugs continue to be first-line therapy for the arrhythmia considered to be a cardiovascular epidemic, clinical research to develop non-pharmacological means of treatment has been unprecedentally intensified during the last decade. Electrical cardioversion is the most successful non-pharmacological method to restore sinus rhythm, also the efficacy and safety of AV node ablation for palliative ventricular rate-controll is established. "Hybrid" therapeutic procedures, involving combinations of pharmacological and non-pharmacological interventions have gained widespread use. Curative transcatheter ablation for arrhythmia prevention is to be considered in case of clinical suggestions that AF is initiated by a primary regular arrhythmia that is amenable to routine catheter ablation (secondary AF). Despite encouraging results, at this point in time, curative catheter ablation for primary AF may offer significant improvement or even cure only for a small subset of patients, mostly young individuals with normal heart, and paroxysmal AF with frequent, symptomatic episodes refractory to multiple antiarrhythmic drugs. These interventions are to be performed in the settings of a clinical research project in some institutions. Regarding pacemaker therapy in case of bradycardia indication, physiologic pacing (AAI or DDD) is associated with significantly lower incidence of atrial fibrillation than ventricular pacing. Large-scale randomized controlled trials are needed to assess the clinical value of specially designed implantable devices to prevent atrial fibrillation in patients with no conventional bradycardia indication. Also, technical optimization and proper clinical evaluation is needed for implantable atrioverters and implantable cardioverter defibrillators capable of atrial cardioversion therapy.

[Drug therapy of atrial fibrillation]

The authors summarize the up-to-date knowledge relating to the pharmacological treatment of atrial fibrillation. They emphasize that drug treatment continues to be in the forefront of the therapy of the arrhythmia, which can now be considered to constitute a cardiovascular epidemic. In the era following the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AF-FIRM) trial, the strategy of pharmacological treatment will certainly change: in place of "rhythm control", which in recent decades has been overforced in patients identical with the elderly, cardiac patients with an impaired left ventricular function who were enrolled into AFFIRM, there will be a more frequent use of ventricular "rate control". Naturally, this does not mean that, in certain patient groups, an effort should not be made to restore and maintain the sinus rhythm. In cases involving congestive heart failure and structural heart disease complicated by a depressed left ventricular systolic function, atrial fibrillation is currently treated with antiarrhythmic drugs possessing low proarrhythmic activity that prolong refractory period (Class 3), and with the even safer mortality-reducing beta-receptor blockers. The classical antiarrhythmic drugs (quinidine, procainamide, disopyramide) are being increasingly forced into the background, and the areas of indication of the novel Na(+)-channel blocker antiarrhythmics (propafenone, flecainide) have also narrowed: they are administered only in the event of atrial fibrillation in patients with a structurally intact heart or left ventricular hypertrophy. After a brief survey of the more important aspects of ventricular rate control, and of the drugs available, the research trends aimed at the progression of the pharmacological treatment of atrial fibrillation are outlined. The clinical introduction of procedures based on myocardial gene therapy is now a realistic therapeutic approach as concerns atrial fibrillation too.

[Torsades de pointes ventricular tachycardia induced by intravenous amiodarone]

The authors report on the case history of a 61 year old woman with hyperthyroidism induced atrial fibrillation, tachycardiomyopathy and congestive heart failure, in whom life threatening ventricular proarrhythmia (torsades de pointes) developed in response to intravenous amiodarone. The patient in a septic state was resuscitated because of ventricular fibrillation. The atrial fibrillation complicated by a high ventricular frequency was slowed down with intravenous amiodarone; additionally, the iodine-containing antiarrhythmic drug was expected to counter thyrotoxicosis. In response to amiodarone (2 x 300 mg), the sinus rhythm was restored, but the excessive post-cardioversion bradycardia led to the development of extreme QT interval prolongation and torsades de pointes ventricular tachycardias that often degenerated into ventricular fibrillation. In connection with this case, the authors survey those electropharmacological and pathophysiological factors which may have played a role in the emergence of ventricular proarrhythmia based on a lengthening of repolarization through the exhaustion of the repolarization reserve.

[History of atrial fibrillation]

The authors review the history of atrial fibrillation, the most frequent clinically observed cardiac arrhythmia. A French "clinicopathologist", Jean Baptist de Sénac (1693-1770), was the first who assumed a correlation between "rebellious palpitation" and a stenosis of the mitral valve. From an analysis of simultaneously recorded arterial and venous pressure curves, the Scottish Sir James Mackenzie (1853-1925) demonstrated that a presystolic a wave cannot be seen on the jugular phlebogram during "pulsus irregularis perpetuus". The first human ECG depicting atrial fibrillation was published by Willem Einthoven (1860-1927) in 1906. The proof of a direct connection between absolute arrhythmia and auricular fibrillation was established by two Viennese physicians, Rothberger and Winterberg. The major discoveries relating to the pathomechanism and the clinical features of atrial fibrillation in the 20(th) century stemmed from the scientific activities of Karel Frederik Wenckebach, Sir Thomas Lewis, Gordon Moe, and Maurits Allessie.

[Pathogenesis and clinical significance of atrial fibrillation]

The authors review the current knowledge relating to the epidemiology, classification and pathogenesis of atrial fibrillation, and then discuss those cardiac electrophysiological changes that play roles in the initiation and/or maintenance of atrial fibrillation. They draw attention to the fact that atrial fibrillation is the most common cardiac arrhythmia in humans, its prevalence increasing continuously with the increase in average lifespan of the population. Atrial fibrillation doubles all-cause mortality, it gives rise to considerable haemodynamic alterations and clinical symptoms, and it is responsible for almost half of the cases of hospitalizations attributable to arrhythmia. Because of the great pathogenetic variety, the most important diagnostic task is to establish the nature of the underlying disease, the arrhythmia substrate, and the predisposing and triggering factors; this permits selection of the therapeutic procedure that is optimum for the given patient. The results of the most recent prospective randomized clinical trials indicate that, in certain groups of patients, it will no longer be absolutely necessary in the future to strive to restore and maintain sinus rhythm: effective oral anticoagulant treatment in combination with pharmacological ventricular rate control ensures the same survival chances and the same quality of life for the patient as those achieved in earlier years with the preferred sinus rhythm-preserving treatment strategy based on pharmacological and/or electrical cardioversions and prophylactic antiarrhythmic drug therapy.

[The clinic for internal medicine at Szeged headed by István Rusznyák]

István Rusznyák was one of the most remarkable members of the internist school of Baron Sándor Korányi, whose functional understanding of body processes made his school famous. Rusznyák started his career at Szeged where he much improved the university internist teaching hospital, originally opened in December 1928, which beside healing was a base of medical research and tuition alike. Rusznyák led the Clinique as a director until World War Two. In developing of the Clinique it was not only Rusznyák's medical expertise and efficiency in organisation which helped but also his wide ranger of personal contacts. In spite of the later he was, nevertheless, deported. After the war he was appointed the post of director of the 1st Clinique of Internal Medicine of the Budapest University. His reputation during his years at Budapest, alike in Szeged made him a well known internist and an effective director. Among his friends he could count the best Hungarian medical experts. The article also touches the rather negative role Rusznyák played for the Stalinist regime in Hungary.

[Wenckebach AV block, as part of vasovagal syncope]

Vasovagal syncope or common faint is the most frequent form of syncopes. With regard to the different involvement of the efferent mechanisms, several forms of the neurally mediated syncope syndromes are recognized. The authors present a case of mixed type vasovagal syncope, diagnosed by tilt table testing. The efferent mechanisms of syncope included Wenckebach type atrioventricular block due to increased vagal tone, and sympathetic withdrawal, reflected by sudden drop in the blood pressure. The significance and interrelationship of these factors are discussed.

[History of atrial fibrillation]

The authors review the history of atrial fibrillation, the most frequent clinically observed cardiac arrhythmia. A French "clinicopathologist", Jean Baptist de Sénac (1693-1770), was the first who assumed a correlation between "rebellious palpitation" and a stenosis of the mitral valve. From an analysis of simultaneously recorded arterial and venous pressure curves, the Scottish Sir James Mackenzie (1853-1925) demonstrated that a praesystolic a wave can not be seen on the jugular phlebogram during "pulsus irregularis perpetuus". The first human ECG depicting atrial fibrillation was published by Willem Einthoven (1860-1927) in 1906. The proof of a direct connection between absolute arrhythmia and auricular fibrillation was established by two Viennese physicians, Rothberger and Winterberg. The major discoveries relating to the pathomechanism and the clinical features of atrial fibrillation in the 20th century stemmed from the scientific activities of Karel Frederik Wenckebach, Sir Thomas Lewis, Gordon Moe and Maurits Allessie.

[Clinical proarrhythmias induced by anti-arrhythmic drugs, non-cardiovascular agents and implantable cardioverter-defibrillators]

The authors survey the electrophysiological mechanisms and clinical spectrum of the aggravation of cardiac arrhythmias provoked by antiarrhythmic drugs, non-cardiovascular agents and implantable cardioverter-defibrillators. The main aspects of the recognition, the differential diagnostics and the therapy are discussed. It is demonstrated that prevention of drug-induced arrhythmogenesis necessitates a fundamental understanding of the risk factors of proarrhythmias and of the clinical pharmacological properties of the drugs that are intended to be used, including proarrhythmic drug interactions. A systematic account is presented of those drugs prescribed in non-arrhythmic diseases which may lead to out-of-hospital cardiac arrest. The proarrhythmias that may be observed in recipients of implantable cardioverter-defibrillators are discussed, as are the undesirable interactions between these devices and antiarrhythmic drugs in such patients.

Gallbladder hypomotility in diabetic polyneuropathy

This study was performed to evaluate the gallbladder motility in long-standing diabetes mellitus. The gallbladder function of diabetic patients was measured by means of quantitative hepatobiliary scintigraphy, and the severity of the associated autonomic and sensory polyneuropathy was determined. The presence of a marked gallbladder hypomotility was established, and a positive correlation was observed between the severity of the autonomic disturbance and the contractile disorder. This study underlines the important role of the neuropathy in the development of gallbladder hypomotility accompanying long-term diabetes mellitus.

[Scientometrics and publishing in Hungarian medical science. Ethical and technical issues]

The authors present an account of the main ethical and technical aspects relating to the measurement of medical publication activities and the compilation of publications lists. It is demonstrated that the Anglo-American scientometric system (Institute for Scientific Information, USA) is currently gaining stable ground in Hungary. At the same time, however, there continues to be a place for a national publication index used to assess Hungarian-language publication activity, for the two systems conveniently supplement one another. The criterion system of medical publishing established by the International Committee of Medical Journal Editors (ICMJE) is described in detail, and is recommended for wide-ranging application in Hungary.

[Antireflux procedures at our unit (1990-1999)]

A retrospective analysis was carried out to evaluate the changing attitude of antireflux surgical practice of the authors. Between 1990 and 1994 24 antireflux procedures were performed. Laparoscopic antireflux surgery was introduced in 1995. Since then 41 laparoscopic and 23 open repairs have been performed. Indication for surgery was always based on thorough preoperative examination protocol including functional tests of the esophagus. Each patients had undergone endoscopic and X-ray examinations. The patients are under continuous follow-up surveillance. During the postoperative follow-up studies more than 2/3 of the patients (61 patients) agreed to carry out the functional tests postoperatively.

RESULTS

The demographic data of patients of the two study periods proved to be comparable. The length of history was 10.5 years in the first group, while it was 8.9 years in the second group. In both groups the surgical repair caused significant reflux control confirmed by decrease of reflux index and number of reflux episodes furthermore by increase of resting lower esophageal sphincter pressure. Actually 4 recurrences are known in the first group and 2 in the second group. One of the 4 recurrences observed in the first period was treated by redo surgery. The patients having recurrences in the second period can easily be managed by medical therapy. There was no mortality and severe morbidity during the study periods. Few patients reported mild temporary dysphagia.

CONCLUSIONS

In a given proportion of reflux patients the individually planned and perfectly performed antireflux surgery offers an acceptable definitive treatment option. The availability of endoscopic surgery enhances this trend, which can be seen all over the world. An increase can be seen in the number of procedures: nearly three times more patients were operated on during the second period. The early clinical results of laparoscopic antireflux procedures are good enough. Good long-term results can be expected if we accept and apply the basic technical principles determined during the open surgery era.

[Scientometric and publication malpractices. The appearance of globalization in biomedical publishing]

Attention is drawn to publication and scientometric malpractices utilized by biomedical authors who do not adhere to the accepted ethical norms. The difference between duplicate/redundant and bilingual publications is defined. In the course of discussion of the manipulations that may be observed in the field of scientometry, it is pointed out that abstract of congress lectures/posters can not be taken into consideration for scientometric purposes even if such abstracts are published in journals with impact factors. A further behavioral form is likewise regarded as unacceptable from the aspect of publication ethics: when a physician who has participated in a multicentre, randomized clinical trial receives recognition (in an appendix or in an acknowledgement of an article) as having contributed data, but assesses this appreciation as co-authorship and thereby attempts to augment the value of his or her publication activity. The effects of globalization on biomedical publication activity are considered, and evidence is provided that the rapidly spreading electronic publication for a give rise to new types of ethical dilemmas. It is recommended that, in the current age of Anglo-American globalization, greater emphasis should be placed on the development of medical publication in the mother tongue (Hungarian).

[Electrocardiographic Osborn wave in hypothermia]

The authors report the first Hungarian case of electrocardiographic Osborn wave with accidental hypothermia (core temperature 32 degrees C). The cellular and ionic mechanisms of the development of J-wave-elevation and the cardiac electrophysiological and ECG changes caused by hypothermia are briefly reviewed. An account is presented of those conditions in which, in a few or in all ECG leads, an Osborn wave or distinct J-point-elevation may be observed.