Shedding of Mycobacterium caprae by wild red deer (Cervus elaphus) in the Bavarian alpine regions, Germany

The number of natural infections with Mycobacterium caprae in wildlife and in cattle in the Bavarian and Austrian alpine regions has increased over the last decade. Red deer (Cervus elaphus) have been recognized as maintenance reservoir; however, the transmission routes of M. caprae among and from naturally infected red deer are unknown. The unexpected high prevalence in some hot spot regions might suggest an effective indirect transmission of infection. Therefore, this study was undertaken to diagnose the occurrence of M. caprae in faeces and secretions of red deer in their natural habitat. A total of 2,806 red deer hunted in this region during 2014-2016 were included in this study. After pathological examination, organs (lymph nodes, lung, heart), excretions and secretions (faeces, urine, saliva and tonsil swabs) were further investigated by qPCR specific for Mycobacterium tuberculosis complex (MTC), M. bovis and M. caprae. Samples tested positive by qPCR were processed for culturing of mycobacteria. In total, 55 (2.0%) animals were confirmed positive for M. caprae by pathological examination, PCR and culturing of the affected organ material. With the exception of one sample, all of the secretion and excretion samples were negative for mycobacteria of the Mycobacterium tuberculosis complex (MTC). From one red deer, M. caprae could be isolated from the heart sac as well as from the faeces. Whole-genome sequencing confirmed that both strains were clonally related. This is the first confirmation that M. caprae can be shed with the faeces of a naturally infected red deer. However, further studies focusing on a higher number of infected animals, sample standardization and coordinated multiple sampling are necessary to improve the understanding of transmission routes under natural conditions.

Haemodiafiltration at increased plasma ionic strength for improved protein-bound toxin removal

AIM

Protein-bound uraemic toxin accumulation causes uraemia-associated cardiovascular morbidity. Enhancing the plasma ionic strength releases toxins from protein binding and makes them available for removal during dialysis. This concept was implemented through high sodium concentrations ([Na⁺ ]) in the substituate of pre-dilution haemodiafiltration at increased plasma ionic strength (HDF-IPIS).

METHODS

Ex vivo HDF-IPIS with blood tested increasing [Na⁺ ] to demonstrate efficacy and haemocompatibility. Haemocompatibility was further assessed in sheep using two different HDF-IPIS set-ups and [Na⁺ ] between 350 and 600 mmol L^-1 . Safety and efficacy of para-cresyl sulphate (pCS) and indoxyl sulphate (IS) removal was further investigated in a randomized clinical pilot trial comparing HDF-IPIS to HD and HDF.

RESULTS

Compared to [Na⁺ ] of 150 mmol L^-1 , ex vivo HDF-IPIS at 500 mmol L^-1 demonstrated up to 50% higher IS removal. Haemolysis in sheep was low even at [Na⁺ ] of 600 mmol L^-1 (free Hb 0.016 ± 0.001 g dL^-1 ). In patients, compared to HD, a [Na⁺ ] of 240 mmol L^-1 in HDF-IPIS resulted in 40% greater reduction (48.7 ± 23.6 vs. 67.8 ± 7.9%; P = 0.013) in free IS. Compared to HD and HDF (23.0 ± 14.8 and 25.4 ± 10.5 mL min^-1 ), the dialytic clearance of free IS was 31.6 ± 12.8 mL min^-1 (P = 0.017) in HDF-IPIS, but [Na⁺ ] in arterial blood increased from 132 ± 2 to 136 ± 3 mmol L^-1 (0 vs. 240 min; P < 0.001).

CONCLUSION

HDF-IPIS is technically and clinically feasible. More effective HDF-IPIS requires higher temporary plasma [Na⁺ ], but dialysate [Na⁺ ] has to be appropriately adapted to avoid sodium accumulation.

[Detailed data collection regarding the utilization of medical services, morbidity, course of illness and outcomes by episode-based documentation in general practices within the CONTENT project]

Billing data for individual patients from General Practice surgeries can be used to analyse primary care utilisation. Making these data available for research and controlling purposes of the German health care system is vital for health services research. Due to the predominant billing purposes, German routine data are unlikely to yield a realistic and differentiated picture of primary care. The General Practice morbidity research network CONTENT (CONTinuous morbidity registration Epidemiologic NeTwork) was established as part of the primary care research grant of the German Federal Ministry of Research and Education. As opposed to other available German routine health care data, the project is designed around episodes of care as the ordering principle of primary care. An episode-based registration integrates the elements reason for encounter, result of the encounter and medical procedure across the quarterly billing timeframe. The use of the International Classification of Primary Care (ICPC) in the CONTENT project supports a specific adaptation to documentation in primary care. As opposed to the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD), ICPC was especially developed for primary care purposes. An episode-based registration and an appropriate classification are prerequisites for a realistic and detailed picture of morbidity and services provided in primary care. An existing electronic medical record (EMR) was extended with domain-specific modules in order to meet the requirements of episode-based registration. The resulting database has already yielded analyses that were impossible to achieve from German routine health care data. Further analyses will subsequently be based on the continuously expanding database and have the potential to shed light on complex epidemiological and health economics research questions. First results point in the direction that the new mode of data collection, in contrast to routinely entered data, features the potential for a more detailed assessment concerning utilisation of medical services, morbidity, course of illness and outcomes in the context of primary care.

On-demand therapy with pantoprazole 20 mg as effective long-term management of reflux disease in patients with mild GERD: the ORION trial

AIMS

To compare safety and efficacy of on-demand pantoprazole 20 mg/40 mg versus placebo in the long-term management of patients with mild gastroesophageal reflux disease (GERD) after heartburn relief.

METHODS

A total of 634 patients with endoscopically confirmed GERD grade 0/I and heartburn were included. During the acute phase, patients were treated with pantoprazole 20 mg once daily for 4 weeks. Those patients relieved from heartburn entered the long-term phase, and were randomly assigned to either treatment group pantoprazole 20 mg, 40 mg or placebo. Over 6 months, patients took study medication on demand (antacids as rescue medication) and discontinued the drug once symptoms abated.

RESULTS

After 4 weeks a total of 87.1%/90.0% of patients were free of heartburn (ITT/PP), and entered the subsequent long-term phase. The perceived average daily symptom load (placebo: 3.93, pantoprazole 20 mg: 2.91, pantoprazole 40 mg: 2.71, ITT) and the number of antacid tablets taken (average number, placebo: 0.68, pantoprazole 20 mg: 0.45, pantoprazole 40 mg: 0.33, ITT) were significantly higher in the placebo than in both pantoprazole groups (p<0.0001), with no statistically significant difference between the two pantoprazole groups. The discontinuation rate due to insufficient control of heartburn was significantly lower in both pantoprazole groups compared to placebo (placebo: 10.9, pantoprazole 20 mg: 2.8, pantoprazole 40 mg: 0.9, ITT).

CONCLUSIONS

Our findings favor on-demand treatment with pantoprazole 20 mg for the long-term management of heartburn in patients with uncomplicated GERD (grade 0/I) with superiority to placebo.

The impact of the risk factor "age" on the early postoperative results of surgery for colorectal carcinoma and its significance for perioperative management

The risks and benefits of surgery for colorectal cancer in old patients have not been unequivocally defined. The present investigation was carried out in 309 hospitals as a prospective multicenter study. In the period between 1 January 2000 and 31 December 2001, a total of 19,080 patients were recruited for the study; 16,142 (84.6%) patients were younger than 80 years (<80) and 2932 (15.4%) were 80 years and older (> or =80). Significant differences between the age groups were observed for general postoperative complications (22.3% for <80 years; 33.9% for > or =80). Specific postoperative complications were identical in both groups. Overall, significantly elevated morbidity and mortality rates were found with increasing age (morbidity: 33.9% vs. 43.5%; mortality: 2.6% vs. 8.0%). The distribution of tumor stages revealed a significantly higher percentage of locally advanced tumors in the older age group (stage II: 28.0% vs. 34.4%). In contrast, no increase in metastasizing tumors was found in the older age group (stage IV: 17.4% vs. 14.1%). Logistic regression showed that, in concert with a number of other parameters, age is a significant influencing factor on postoperative morbidity and mortality. The increase in postoperative morbidity and mortality rates associated with aging is a result of the increase in general postoperative complications, in particular, pneumonia and cardiovascular complications. Age as such does not represent a contraindication for surgical treatment. The short-term outcome and quality of life are of overriding importance for the geriatric patient.

Evaluation and cultural adaptation of a German version of the AIMS2-SF questionnaire (German AIMS2-SF)

OBJECTIVES

The aim of the study was to examine the validity of a translated and culturally adapted version of the Arthritis Impact Measurement Scales 2, Short Form (AIMS2-SF) in patients suffering from osteoarthritis (OA) in primary care.

METHODS

A structured procedure was used for the translation and cultural adaptation of the AIMS2-SF into German. The questionnaire was administered to 220 primary care patients with OA of the knee or hip. Test-retest reliability was tested in 35 randomly selected patients, who received the questionnaire a second time after 1 week. The physical scale of the original AIMS2-SF was divided into an 'upper body limitations' scale and a 'lower body limitations' scale.

RESULTS

With values ranging from 0.52 to 0.97 for Pearson's r, item-scale correlations were reasonably good. The discriminative power of separate scales was also good, reflected in low values for correlation between different scales, indicating little redundancy. Only two items (13 and 15) referring to the symptom scale showed item-scale correlation of r = 0.72 and r = 0.67, respectively with the lower body limitation scale. The assessment of internal consistency reliability also revealed satisfactory values: Cronbach's alpha was > or =0.83 for all scales, except for the social interaction scale (0.66). The test-retest reliability, estimated as the intraclass correlation coefficient (ICC), exceeded 0.85 except for the affect scale (0.72). Substantial floor effects occurred in the upper limb scale (33.8%). Principal factor analysis confirmed the postulated three-factor structure with physical, physiological and social dimensions, explaining 49.8, 14.1 and 6.4% of the variation, respectively. The assessment of external validity revealed satisfactory correlations with the corresponding WOMAC (Western Ontario and McMaster Universities Arthrosis Index) scales. As expected, correlations with radiological grading were moderate to low. The correlation with the physician's assessment was high in the scales that were dominated by physical factors, but rather low in the areas of health, which were found to be dominated by psychological or social factors.

CONCLUSION

The German AIMS2-SF is a reliable and valid instrument to assess the quality of life in primary care patients suffering from OA. When addressing the different impacts of OA, the physical scale should be divided into an upper body scale and a lower body scale. The floor and ceiling effects revealed are in accordance with the disease characteristics of the study sample and do not limit the significance of the questionnaire.

Improvement of prognostic power of the Child-Pugh classification of liver cirrhosis by hyaluronan

BACKGROUND/AIMS

Modifications of the Child-Pugh classification of liver cirrhosis by incorporation of hyaluronan were tested to improve the prognostic power for long term evaluation of liver cirrhosis in 126 patients observed over a period of 10 years.

METHODS

Serum concentrations of HA were determined at study entry. Statistical analysis included Kaplan-Meier life tables and stepwise multivariant Cox-regression analysis for each parameter of Child-Pugh classification and hyaluronan. Prognostic models were developed by exchanging prothrombin time, albumin and encephalopathy by HA in different combinations.

RESULTS

Based on a good single correlation between hyaluronan (0.62) and clinical course (P<0.01) we conclude that models with hyaluronan instead of albumin or encephalopathy and with or without shifted threshold values of bilirubin and albumin are superior for the prediction of the long term prognosis. In Cox-regression analysis, apart from hyaluronan and bilirubin, no other parameters contributed to an improvement.

CONCLUSIONS

We conclude that a modification of the Child-Pugh classification of liver cirrhosis by inclusion of HA significantly improves the predictive power of CP, especially in alcoholic etiology. A prospective validation of the newly defined scores needs to be done in the future.

Comparable efficacy of pantoprazole and omeprazole in patients with moderate to severe reflux esophagitis. Results of a multinational study

AIM

To compare the efficacy and tolerability of pantoprazole 40 mg and omeprazole MUPS 40 mg in patients with moderate to severe gastroesophageal reflux disease (GERD).

METHODS

In this randomized, double-blind, parallel-group, multicenter study conducted in Austria, Germany, Portugal, Switzerland and The Netherlands, patients with endoscopically confirmed moderate to severe GERD (Savary/Miller esophagitis grade II/III) were enrolled. They received a once-daily dose of either 40 mg pantoprazole or 40 mg omeprazole MUPS. Healing was determined by endoscopy after 4 weeks of treatment. If patients were not healed, treatment was extended for another 4 weeks. An additional endoscopy was performed in these cases after 8 weeks of treatment. Healing was determined by endoscopy after 4 and 8 weeks. In addition, treatment effect on symptoms was evaluated by the investigator using a questionnaire assessing heartburn, reflux regurgitation and pain on swallowing at each visit, as well as by a self-administered questionnaire comprising further 24 gastrointestinal symptoms. Analyses were performed for the intention-to-treat (ITT) and the per-protocol (PP) population. In addition, patients with high compliance (HC: 90% </=110%) were considered in a separate group. Adverse events and the influence of the Helicobacter pylori status were investigated.

RESULTS

A total of 669 outpatients were enrolled in the study, with 337 patients receiving pantoprazole and 332 omeprazole MUPS. The PP population consisted of 552 patients, 282 treated with pantoprazole and 270 with omeprazole MUPS. The healing rates in both treatment groups were shown to be equivalent and were higher in patients who adhered closely to the administration protocol (HC). According to ITT (ITT(HC)) analyses, healing rates were 65.3% (77.4%) in the pantoprazole and 66.3% (74.7%) in the omeprazole group after 4 weeks. Furthermore, patients infected with H. pylori had slightly but not significantly higher healing rates than those with a negative test result. The safety profile of both treatments was comparable.

CONCLUSION

Pantoprazole 40 mg and omeprazole MUPS 40 mg were equivalent with respect to healing after 4 and 8 weeks of treatment in patients with reflux esophagitis grade II/III. Overall, HC patients had higher healing rates than the regular compliant patients. Both drugs were well tolerated and safe.

Diagnosis of perforated gastric ulcers by ultrasound

Patients with a perforation of the gastrointestinal tract need fast confirmation of diagnosis and early treatment to improve outcome. Plain abdominal x-ray does not always prove the perforation particularly at early stage. We report about a 62 year-old woman complaining of consistent abdominal pain with sudden onset. Ultrasound was taken as first diagnostic measure, revealing a perforation. The leakage was located in the stomach. Radiography confirmed the pneumoperitoneum without indicating the perforated location. During operation the perforated gastric ulcer was found and sutured. This case report points out the reliability of ultrasound in diagnosing a pneumoperitoneum. Additionally it provides a summary of ultrasound signs seen in perforated gastric and duodenal ulcers and a review of literature.

[Deficits in socioeconomic and psychosocial support of HIV-positive women]

Despite increasing numbers of heterosexually transmitted HIV-infected women and high numbers of female i.v.-drug users within HIV-infected population the subject of HIV-infection in women has been of low interest during the past years in Germany. This prospective study investigated the economic, social and psychological situation with regard to the special situation of this group. While there was no difference in clinical parameters we found a worse economic situation of HIV-positivity in women. Concerning the psychosocial situation there were few differences, but HIV-infected women sought help by voluntary workers more often. Specific education and socioeconomic support of HIV-infected women are conditions for the success of antiretroviral therapy of HIV-infection which has recently become more demanding and complex.

[Public health economic aspects of antiretroviral therapy. Can we afford to do less?]

In Germany, politically motivated economic considerations are becoming even more important. In this connection, scientific research into the health system is not limited merely to a consideration of costs, but utilizes the same methods and conceptual models as economic research in general to investigate defined problems. The reduction of illness-related loss of production and quality of life to monetary units in the models used, often stimulates critical discussions of the ethical permissibility of such an approach. Public discussion of such models then makes it possible to justify rationally founded allocation decisions and to expose and thus prevent hidden forms of rationing. The medically successful concept of long-term administration of highly active antiretroviral combination treatment (HAART) was first considered by numerous studies to be cost-effective solely on the basis of the saving of inpatient treatment costs--a stance that in the light of the life-shortening HIV infection should not be thought to be only basis for the decision. Owing to a lack of experience with the long-term prognosis under HAART, it is difficult to assess indirect costs for HIV infection. An assessment of the quality of life in the symptom-free stages of HIV infection depends largely on coping strategies, so that the results of studies on quality of life measurement under antiretroviral treatment must not lightly be interpreted as a function of a given therapeutic strategy. Given the high costs of HIV infection to the economy, the marked reluctance to provide the necessary funding for research in the area of epidemiological monitoring, specific preventive measures and vaccination strategies is to be regretted.

Angiotensin II increases erythropoietin production in healthy human volunteers

BACKGROUND

A number of animal studies and our own clinical trials point towards a possible influence of the renin-angiotensin-system (RAS) on erythropoietin (EPO) production. In this study we investigated the role of angiotensin II in the regulation of EPO production in humans.

METHODS

After a hemorrhage of 750 ml as a basic physiological stimulus 72 healthy male volunteers received in a parallel design either placebo (physiologic electrolyte solution) for 6 h, angiotensin II i.v. for 6 h (1-3 microgram min-1, sufficient to increase systolic blood pressure by 20 mmHg), the selective AT1-receptor antagonist losartan, the ACE-inhibitor captopril, angiotensin II + losartan, or angiotensin II + captopril.

RESULTS

Administration of angiotensin II alone and in combination with captopril resulted in a significantly higher Cmax EPO (67% higher vs. placebo, P < 0.05) and AUCEPO (0-24h) (40% higher vs. placebo, P < 0.05). In the groups receiving losartan or captopril alone or the combination of angiotensin II + losartan no significant difference of Cmax EPO and AUCEPO(0-24h) compared to placebo could be detected.

CONCLUSIONS

This study shows in a model of controlled, basic physiological stimulation of renal EPO production that angiotensin II is able to increase EPO levels in humans. This effect of angiotensin II can be blocked by the specific AT1-receptor antagonist losartan but not by the ACE-inhibitor captopril. The result may be interpreted as a hint that one signal for the control of EPO production in humans may be mediated by angiotensin II (AT1)-receptors.

Impaired glucose tolerance, beta cell function and lipid metabolism in HIV patients under treatment with protease inhibitors

OBJECTIVES

To evaluate metabolic abnormalities, beta-cell function, lipid profile and vascular risk factors in HIV patients on protease inhibitors (PI).

DESIGN

Prospective cross-sectional study.

METHODS

Thirty-eight HIV-1-infected patients receiving at least one PI were compared with 17 PI-naive HIV patients in an oral glucose tolerance test (OGTT). Serum glucose, insulin, proinsulin, and C-peptide were determined. The fasting lipid pattern was analysed using electrophoresis and the assessment of apolipoproteins including lipoprotein (a). Fibrinogen, homocysteine, and anticardiolipin antibodies were also assessed.

RESULTS

Twenty-seven (71%) of the PI-treated group had detectable hyperlipidaemia. Isolated hypertriglyceridaemia was present in 12 patients (44%), two (7%) of them had type V and 10 (37%) subjects had type IV hyperlipidaemia (Frederickson classification). Type IIb hyperlipidaemia defined as an increase of both very-low-density lipoproteins (VLDL) and low-density lipoproteins (LDL) was found in 10 (36%) subjects, and five (18%) patients presented with isolated hypercholesterolaemia (type IIa). PI treatment was associated with significant higher fasting cholesterol, triglycerides, LDL and VLDL levels. Apolipoprotein B and E concentrations were significantly increased in patients receiving PI. Elevated concentrations of lipoprotein (a) (> 30 mg/dl) were detected in six (16%) of the hyperlipidaemic patients on PI. Eighteen (46%) patients on PI had impaired oral glucose tolerance and five (13%) had diabetes. Although four (24%) of the PI-naive patients were glucose intolerant, none had diabetes. Fasting concentrations and secretion response of insulin, proinsulin, and C-peptide to glucose ingestion was significantly increased in the PI-treated group suggesting a beta-cell dysfunction in addition to peripheral insulin resistance. Beta-cell abnormalities were associated with the abnormal lipid pattern and PI treatment.

CONCLUSION

Combination drug regimens including PI are accompanied by impaired glucose tolerance, hyperproinsulinaemia as an indicator for beta-cell dysfunction, and lipid abnormalities proved to be significant risk factors for coronary heart disease. Moreover, PI may have an impact on the processing of proinsulin to insulin.

[Endoscopic interventions of the biliary tract in postoperative complications after cholecystectomy for preventing relaparotomy]

The postoperative complication rate of laparoscopic cholecystectomy (LC) is about 5-6%. The most frequent complications are residual gallstones in the common bile duct, biliary leckage, biliary fistula and duct stenosis. In the period between 01.11.94 and 01.04.96 we performed 1620 endoscopic retrograde cholangio pancreatographies including 410 papillotomies at the second Department of Medicine in the Clinic of Suhl. Thereby in 2.1% (34 cases) of patients a complication after laparosopic cholecystectomy was seen and endoscopically controlled. Residual bile duct stones were removed without any problems by papillotomy and stone extraction. Biliary leckage were brigded by stent implantation. In case of aberrant cystic duct it was also possible to implant a stent depending on anatomical situation. All patients were followed up over a period of 6 to 8 month after endoscopic procedure. All except two patients showed an occlusion of biliary leckage and the bile duct stent could be revved. In one case, a younger patient, with a failed endoscopic occlusion of biliary fistula had to undergo a further operation because of residual gallbladder tissue. In the other case, a 84-years old patient, we use a new method, developed at our department, for selective embolization of the cystic duct to prevent a relaparotomy. The leckage was sufficiently closed. Endoscopic intervention is indicated in case of postoperative complication after LC and successful in the majority of cases. This should primarily discussed between surgeon and physician. Only secondarily a relaparotomy should be performed, if endoscopic procedures have failed.

[Endoscopic diagnosis and therapy of cholecysto- and choledocholithiasis]

Not only for systematical reasons a differentiation of gallstones disease between cholecystolithiasis and choledocholithiasis is sensible. Although the two diseases are basically caused by gallstones, they generally differ in diagnostic and therapeutic strategies. While the cholecystolithiasis is the domain of visceral surgeons and today almost exclusively and definitively cured by microinvasive cholecystectomy, for the treatment of choledocholithias there are required the endoscopic procedures of physicians.

[Magnetic resonance imaging vs. three-dimensional scintigraphy in the diagnosis and monitoring of mandibular osteomyelitis]

Bone scintigraphy is routinely used in the diagnosis of lower jaw osteomyelitis; however, the radiation dosage of 3.5 mSv is quite high. Magnetic resonance imaging (MRI) gives information about soft tissue and bone marrow alterations. This study compares the sensitivity of the two imaging modalities in the diagnosis of lower jaw osteomyelitis. Thirteen patients with clinical signs of the disease were examined and followed up using both methods, three-phase bone scintigraphy and MRI. Compared to three-phase bone scintigraphy, MRI has the same diagnostic sensitivity. However in one case of active osteomyelitis bone scintigraphy showed a false-negative result. MRI once indicated a higher activity rate but never failed to provide the diagnosis. In addition, it gives exact information about the location, size and involvement of the soft tissue. A STIR sequence should be performed in addition to the native and contrast-enhanced T1-weighted spin echo sequence. The metal artifacts of the antibiotic chain on the MRI can be eliminated by replacing the wire by nonresorbent suture material. In the diagnosis of lower jaw osteomyelitis, three-phase bone scintigraphy can be replaced by the MRI.

[Magnetic resonance tomography in the diagnosis of mandibular osteomyelitis]

PURPOSE

A prospective study of the value of MRI in the diagnosis of osteomyelitis of the mandible with special reference to the suitability of different MR sequences.

MATERIAL AND METHODS

In 13 patients, average age 55 years (12-82), with clinical suspicion of osteomyelitis of the mandible, 18 MRI examinations were carried out (STIR, TSE T2, proton and SE T1 weighted scans with and without contrast, slice thickness 3.5 to 6 mm). Image quality of the sequences was evaluated as well as the suitability of the various sequences for showing the lesion, its location and extent. Activity of the osteomyelitis was judged by the degree of contrast uptake and was correlated with 3-phase bone scintigraphy and with histological findings.

RESULTS

In 9 of the 14 cases the findings on MRI and of the scintigraphy agreed with the histology. In two patients the activity of the inflammatory process was exaggerated by the MRI. In another follow-up examination it was slightly underestimated. All lesions were shown to be highly active by the histology were recognized as such by MRI. For the localisation and recognition of the extent of the inflammatory processes STIR sequences and T1 weighted non-enhanced SE sequences proved the most suitable. Contrast medium is essential to evaluate the inflammatory activity.

CONCLUSION

MRI is a sensitive diagnostic method; it is as good as 3-phase bone scintigraphy in demonstrating osteomyelitis of the mandible and of its activity but is superior for showing the pathological anatomy.

Serum laminin and hyaluronan in liver cirrhosis: markers of progression with high prognostic value

BACKGROUND/AIMS

In a prospective study with a mean follow-up period of 12.5 +/- 3.5 months, we investigated the extracellular matrix components laminin and hyaluronan in serum for their diagnostic value in portal hypertension and in clinically severe complications of progressive liver cirrhosis.

METHODS

In 38 patients with liver fibrosis (n = 4) and cirrhosis (Child A: n = 17, B: n = 7, C: n = 10), the serum concentrations of laminin and hyaluronan were determined. Portal hypertension was assessed by endoscopic control of the esophageal varices and by Doppler sonography of the portal blood flow.

RESULTS

Neither laminin nor hyaluronan correlated with portal hypertension, but highly significantly increased (p < 0.001) concentrations of 3.25 +/- 0.2 U/ml (laminin) and 493 +/- 248 ng/ml (hyaluronan) were found in patients with complications of liver cirrhosis when compared to those without complications (Ln: 2.13 +/- 0.26 U/ml, HA: 206 +/- 184 ng/ml). At cut-off levels of 2.6 U/ml (laminin) and 200 ng/ ml (hyaluronan), the diagnostic sensitivity and specificity for severe complications of liver cirrhosis was 0.71 and 0.86 (Ln) and 0.90 and 0.67 (HA), respectively. The positive predictive values were of 0.8 (laminin) and 0.6 (hyaluronan). The relative risk of patients presenting elevated concentrations of laminin or hyaluronan at the start of the study for later development of severe complications was 2.7.

CONCLUSIONS

Both parameters, especially serum laminin, can be used as prognostic markers in addition to the Child criteria in liver cirrhosis.

[The clinical value of laminin determination in advanced liver cirrhosis]

OBJECTIVE

To test prospectively whether serum laminin levels, which is taken to indicate portal hypertension, can predict the occurrence of severe complications in advanced cirrhosis of the liver.

PATIENTS AND METHODS

In 38 patients (21 men, 17 women; mean age 55.6 +/- 13.4 years) with liver fibrosis (n = 4) or liver cirrhosis (n = 34) serum laminin was measured by a commercially available radioimmunoassay (Behring, Marburg). The severity of liver cirrhosis was graded according to the Child-Pugh-Christensen criteria. Portal hypertension was assessed by standard endoscopic methods and portal-vein duplex sonography. Within a mean observation period of 12.5 +/- 3.5 months, the following were used as signs of severe clinical complications of liver cirrhosis: stages III and IV of hepatic coma, treatment-refractory ascites, portal vein thrombosis and death due to multi-organ failure. Acute bleeding from oesophageal varices was confirmed by emergency endoscopy.

RESULTS

At laminin concentrations of 3.25 +/- 0.20 U/ml there was a highly significant correlation (P < 0.001) with complications of liver cirrhosis. Using 2.6 U/ml as the critical level, the occurrence of severe complications had a positive predictive value of 0.80 with a sensitivity and specificity of 0.71 and 0.86 respectively. This means that a patient who, at the beginning of the study period, had a raised laminin concentration, had a relative risk of 2.65 (1.41-4.97) for later severe complications.

CONCLUSION

Serum laminin concentration has a diagnostic efficiency of 0.79 as a prognostic indicator and can thus serve as a valuable addition to the Child-Pugh-Christensen classification of liver cirrhosis.

Portal duplex sonography in liver cirrhosis. A useful supplement to endoscopic evaluation of bleeding risk of esophageal varices?

BACKGROUND

In a prospective study we investigated whether the endoscopic assessment of the bleeding risk of esophageal varices could be supported by portal duplex sonography.

METHODS

Over the time span of 2.5 years (range, 13 +/- 5 months) we observed 41 patients with liver cirrhosis. During that time 17 patients had acute esophageal variceal hemorrhage and constituted the bleeding group, and the remaining 24 patients without a hemorrhage constituted the non-bleeding group.

RESULTS

Within the bleeding group the mean portal blood flow velocity (Vm) was 0.093 +/- 0.033 m/sec, and the mean flow volume (Fm) was 0.371 +/- 0.173 l/min. Both results were significantly lower than the corresponding results of the nonbleeding group (p < 0.017; p < 0.05). By assuming cut-offs for Vm of 0.12 m/sec and for Fm of 0.420 l/min, we obtained a diagnostic sensitivity for hemorrhage of 0.88 and 0.65.

CONCLUSION

Our results show that portal duplex sonography may improve the evaluation of endoscopically ascertained bleeding risk of esophageal varices.

[Diagnostic value of portal duplex ultrasound in liver cirrhosis]

AIM

In a prospective study we investigated if the endoscopical evaluation of the bleeding risk of esophageal varices in cirrhotics could be improved by additional duplex sonography of the portal vein.

METHOD

The trial involved 41 patients with endoscopically diagnosed esophageal varices (27 male, 14 female) who were followed up over a period of 30 months (mean of 13 +/- 3). According to the Child-Pugh-Turcotte -classification, 14 patients were classified as grade A, another 14 as grade B, and 13 as grade C. The cause of the cirrhosis included virus infection (n = 14), alcohol (n = 17) and miscellaneous disorders (n = 9, primary biliary = 3, autoimmune = 2, idiopathic = 4).

RESULTS

During the observation time, 17 patients who developed an acute esophageal variceal hemorrhage were put in the bleeding group (mean portal flow velocity Vm = 9.29 +/- 3.31 cm/s, mean flow volume Fm = 371 +/- 173 ml/min), while the remaining 24 patients formed the non-bleeding group (Vm = 13.29 +/- 5.12 cm/s, FV = 500 +/- 200 ml/min). The bleeding group had significantly lower mean portal flow velocities (p < 0.017) and mean flow volumes (p < 0.05) than the non-bleeding group. By adopting cut-off values of 12 cm/s for Vm and 420 ml/min for FV we obtained a diagnostic sensitivity for predicting esophageal variceal hemorrhage of 0.88 and 0.65 respectively.

CONCLUSION

Portal duplex sonography may improve the evaluation of bleeding risk in patients wit endoscopically diagnosed esophageal varices and could influence the decision for prophylactic treatment.

Fibronectin in human bile fluid for diagnosis of malignant biliary diseases

In a preliminary study, we demonstrated a strong association between the concentration of the glycoprotein fibronectin (FN) in human bile fluid and the presence of malignant biliary diseases. We now present the results of measurements of total FN (tFN) and cellular FN (cFN) within a larger group of 71 patients. Bile fluid was collected during routine endoscopic retrograde cholangiography or by transhepatic puncture, respectively, from patients admitted for examination/treatment of biliary obstruction. Determination of tFN in bile was performed using a previously described time-resolved fluorescence immunoassay (TRFIA). For cFN, a newly developed TRFIA, using a specific monoclonal antibody for the EDA epitope of cFN, was applied. Within the noncarcinoma group of patients (n=50), consistently low concentrations of tFN (median = 5 ng/mL) were found. In most of these cases, the corresponding concentrations of cFN were below the detection limit (2.6 ng/mL) of this assay. Highly significantly elevated concentrations were found for both tFN (median = 1,220 ng/mL) and cFN (median = 243 ng/mL) in the carcinoma group (n = 21) in comparison with the noncarcinoma group (P < or = .01). By adopting cutoff values of 60 ng/mL for tFN and >0 ng/mL for cFN, diagnostic sensitivities for carcinoma of the biliary tract of 0.89 and 0.92, and specificities of 0.96 and 0.98, respectively, were computed. FN in bile fluid is suggested as a sensitive, specific, and easily determined marker for differential diagnosis of malignant and benign diseases of the biliary tract.

Omeprazole-amoxycillin therapy for eradication of Helicobacter pylori in duodenal ulcer bleeding: preliminary results of a pilot study

Thirty-five patients with duodenal ulcer bleeding and Helicobacter pylori-colonization were assigned to receive 2 x 20 mg omeprazole and 3 x 750 mg amoxycillin daily for 2 weeks. Eradication was defined as no evidence of H. pylori infection by urease test and by histology 4 weeks after completion of therapy. Two patients were lost to follow up. All ulcers healed completely (100% ulcer healing rate). Twenty-nine out of the 33 patients were H. pylori-negative (87.9% eradication rate). Three patients complained of typical side effects of amoxycillin (9.1% side effect rate). The patients were prospectively followed for 12 months. After ulcer healing, no maintenance therapy was given. One of the 29 patients in whom H. pylori eradication had been successful suffered a second ulcer hemorrhage with H. pylori reinfection (3.4% relapse rate of ulcer bleeding), and this was managed endoscopically. Recurrent ulcer hemorrhage occurred in 2 out of 4 H. pylori-resistant patients. At the end of the follow-up period, of the patients in whom H. pylori eradication had been initially successful, only the patient with re-bleeding remained reinfected. The 4 H. pylori-resistant patients showed persistent H. pylori colonization. In conclusion, omeprazole plus amoxycillin is a safe and effective treatment for eradicating H. pylori; this treatment reduces the relapse rate of duodenal ulcer bleeding.

Diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device

OBJECTIVE

To investigate the effectiveness of prophylactic injection therapy in vascular malformations after acute hemorrhage. To review recent advances in diagnosis and treatment control of bleeding intestinal angiodysplasias with an endoscopic Doppler device.

DESIGN

Open prospective study involving 34 patients with bleeding from gastroduodenal and colorectal angiodysplasias.

INTERVENTIONS

In order to detect the superficial arterial vessels responsible for the bleeding, a total of 79 lesions were scanned by transendoscopic Doppler ultrasonography. 70 vascular ectasias (88.6%) were Doppler-positive and had injection therapy with epinephrine and polidocanol.

RESULTS

Out of the 70 sclerosed angiodysplasias, 63% (90.0%) could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 7 visible malformations, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 1 year of follow-up, 2 of the 34 treated patients (5.88%) relapsed with actively bleeding cecal angiodysplasias. After repeated endoscopic hemostasis, no more hemorrhage was observed in both patients. The results were partly published in previous publications.

CONCLUSION

Endoscopic Doppler ultrasonography may help in identification and treatment of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

Extragastric Dieulafoy's disease as unusual source of intestinal bleeding. Esophageal visible vessel

Dieulafoy's disease is a gastric vascular malformation, which typically causes massive hemorrhage. The lesion is most often found in the proximal stomach, but has also been reported in the esophagus and in the small intestine. Three patients with esophageal Dieulafoy's anomaly and recurrent bleeding are reported. For the first time, transendoscopic Doppler ultrasound was used to identify arterial blood flow from the lesions. The ulcerations were treated by injection of adrenaline. Successful therapy resulted in the disappearance of arterial pulsations and no rebleeding occurred. Doppler-controlled endoscopic intervention should be the first line of treatment in the esophageal vessel stump.

[A rare etiology for HBs-Ag negative acute hepatitis B--coinfection by hepatitis B and delta]

An unusual case of a 25-year-old male Italian is reported. The patient endured an acute hepatitis without detectable HBs-antigen by coinfection with hepatitis-B and Delta. Coincidently, a cured hepatitis-C was present. Firstly hepatitis-B-virus DNA could be demonstrated in a small quantity by serodiagnosis (6 pg/ml, hybridization technique). Subsequently, the identification of B-virus DNA was only possible in liver tissue (PCR-technique), but no longer by serodiagnosis. The probable enduring inhibition of hepatitis-B-virus replication by Delta virus resulted in a self limitation of the disease within 2 months (HDV-RNA negative, HBs-Ag and HBe-Ag negative; Anti-HBs negative, Anti-HBe and Anti-HBc positive). In spite of negativation of replication markers for hepatitis-B a subsequent reactivation of the infection was possible by viral material which persisted in liver tissue.

[Bouginage of peptic esophageal stenoses. Results of one year with long-term omeprazole medication]

METHOD

Within the framework of an open prospective study, 47 patients with chronic reflux esophagitis, unresponsive to H2-receptor blockers and complicated by stenosis, underwent endoscopic bougienage. Unsuccessful treatment with H2-receptor blockers was followed in all patients by antisecretion treatment with omeprazole at a dose of 40 mg/day.

RESULTS

At the latest after 3 months, stenotic and inflammatory changes had cleared up in all patients and under continued omeprazole over the long-term, remission of at least one year was achieved.

CONCLUSION

A combination of endoscopic bougienage and simultaneous treatment with the proton pump blocker, omeprazole, represents effective treatment of chronic reflux disease complicated by stenosis.

[Fibronectin in human bile--a new parameter for diagnosis of malignant bile duct processes?--A pilot study]

In a pilot study it was investigated whether concentration of the glycoprotein fibronectin in the bile fluid can assist in differentiating between malignant and benign biliary tract obstructions. During endoscopic-retrograde cholangiography (ERC) and percutaneous transhepatic cholangiography (n = 3) native bile was aspirated in 29 patients. The concentration of fibronectin was determined by time resolved fluorescence immuno-assay. In 19 patients no biliary malignoma was present (choledocholithiasis: n = 9, normal finding: n = 10). Ten patients suffered from biliary or pancreatic cancer (infiltrating pancreatic cancer: n = 6; primary biliary tract cancer: n = 3, Klatskin tumor: n = 1). In the non malignant group a median fibronectin concentration of 12.0 ng/ml (lower-upper quartile 5-30 ng/ml) was found. A highly significantly elevated (p < 0.001, non parametric Kruskal-Wallis-test) median fibronectin concentration of 1675 ng/ml (lower-upper quartile 155-3430 ng/ml) could be determined in the malignant group. Our results show that in analogy to ascites, the concentration of biliary fibronectin is an important and easily determinable parameter in the differential diagnosis of benign und malignant diseases of the biliary tract.

Diagnosis and treatment control of bleeding colorectal angiodysplasias by endoscopic Doppler sonography: a preliminary study

The diagnostic accuracy and practical impact of trans-endoscopic Doppler ultrasonography were prospectively investigated in an open preliminary study of patients with hemorrhage from colonic vascular malformations. From January 1, 1991, to December 31, 1992, 437 consecutive patients were seen with lower gastrointestinal bleeding. In 15 cases the source of hemorrhage proved to be colorectal angiodysplasias (3.4%). In all cases bleeding had stopped spontaneously before the endoscopic examination. Upper gastrointestinal causes of bleeding were excluded endoscopically in each patient. To detect the superficial arterial vessels responsible for the hemorrhage a total of 32 lesions were scanned by trans-endoscopic Doppler ultrasonography. Twenty-nine vascular malformations in 12 patients were Doppler-positive (91%) and 3 lesions in 3 patients were Doppler-negative without an arterial signal. All Doppler-positive lesions had injection therapy with epinephrine and polidocanol. Twenty-six of the 29 sclerosed angiodysplasias (90%) in 9 patients could not be found endoscopically 2 weeks later, confirming the success of therapy. Doppler noise was still recorded in 3 visible malformations in the remaining 3 patients, indicating insufficient treatment. Further injections were made into these lesions, and the vascular anomalies were finally eliminated. During 6 months of follow-up, one of the 12 treated patients relapsed with an actively bleeding cecal angiodysplasia. After repeated endoscopic hemostasis, no further hemorrhage was observed in this patient. No bleeding recurred in the 3 patients with Doppler-negative lesions. Endoscopic Doppler sonography may help in the identification of intestinal angiodysplasias. The technically simple method allows objective evaluation of the endoscopic findings and enables monitoring of local endoscopic therapy.

[Endoscopic pseudocysto-gastric drainage involving the stomach after Billroth II operation]

A 45 years old female patient developed a large pseudocyst after an acute pancreatitis in 1987. In 1982 gastric resection with Billroth's anastomosis was performed. The patient underwent surgical internal and percutaneous external drainage in 1988, which both resulted unsuccessfully. The current admission was due to a complete occlusion of the gastric anastomosis, induced by a recurrent pseudocyst of 9.2 x 7.3 cm in diameter. Endoscopically guided pseudocysto-gastric drainage by means of electrocauterization was successful with nearly complete evacuation.

[Proctoscopic Doppler ultrasound in diagnosis and therapy of symptomatic first degree hemorrhoids ]

Within the framework of a prospective study two comparable collectives with each 62 patients and symptomatic first grade hemorrhoidal disease were examined. Guiding symptom was painless hematochezia. The hemorrhoids of collective A were evaluated with the aid of transproctoscopic Doppler ultrasound. The depth of the vessels was determined and a Doppler located injection therapy was performed. The patients of collective B were only investigated by means of proctoscopy and sclerosed without Doppler. Sclerosing injection was carried out in all cases with 6 ml Phenylamygdalic oil by 3, 7 and 11 o'clock lithotomy position. Success of therapy was controlled in all patients 2 weeks later Doppler sonographically. In 87% of the Doppler controlled treated patients the hemorrhoids were completely eliminated and no more arterial blood flow could be scanned. On the contrary only 37% of the initially not Doppler scanned patients were cured. Endoscopic Doppler ultrasound is and effective method in evaluation and treatment of symptomatic first grade hemorrhoids.