Cardiac abnormalities as a new manifestation of nonalcoholic fatty liver disease: echocardiographic and tissue Doppler imaging assessment

Nonalcoholic fatty liver disease (NAFLD) is linked to the metabolic syndrome. The aim of the present study is to determine the effect of the metabolic syndrome on left ventricular (LV) geometry and function using as a model patients with NAFLD. Thirty-eight patients with NAFLD, less than 55 years of age and with a normal exercise test, were compared with an age and sex-matched control group. Patients with diabetes mellitus, hypertension, and body mass index>40 were excluded. A complete echocardiographic study including tissue Doppler imaging (TDI) was performed. The following parameters were assessed by echo Doppler: peak velocities of early (E) and late (A) diastolic filling, E/A ratio, flow propagation velocity (Vp). Using TDI early diastolic velocity (E'), and systolic velocity (S') of mitral annulus were obtained. The patients with NAFLD had a significantly higher body mass index (31.4+/-5 vs. 26.4+/-4 kg/m, P=0.01), higher glucose (100.6+/-13 vs. 83.0+/-10 mg/dL, P=0.01), and triglyceride levels (126.5+/-44 vs. 206.5+/-67 mg/dL, P<0.001). Increased thickness of the intraventricular septum, posterior wall (11.03+/-2.2 vs. 8.9+/-2.9 mm, P=0.001; 8.5+/-1.7 vs. 9.7+/-2.3 mm, P=0.04), and larger LV mass and LV mass/height (160.7+/-58.7 vs.115.3+/-35.4 g, P=0.001 and 92.6+/-29.5 vs. 69.2+/-19.8 g/m, P=0.001, respectively) were found in NAFLD group. LV systolic function was similar in both groups. Patients with NAFLD had a lower E (73.6+/-11.0 vs. 86.4+/-20.0 cm/s, P<0.006) and E/A ratio (1.0+/-0.3 vs. 1.76+/-0.8 P<0.0001). Moreover, the Vp and the E' on TDI were significantly lower compared with the control group (49.0+/-9.7 vs. 74.7+/-18.4 cm/s, P<0.0001 and 10.3+/-2.0 vs. 13.8+/-1.7 cm/s, P<0.0001, respectively). On multivariate analysis the E' on TDI was the only independent parameter associated with NAFLD. In conclusion, patients with NAFLD in the absence of morbid obesity, hypertension, and diabetes have mildly altered LV geometry and early features of left ventricular diastolic dysfunction. Early diastolic velocity on TDI was found to be the only index that could identify the patients with NAFLD and metabolic syndrome.

Anapleurotic CO(2) Fixation by Phosphoenolpyruvate Carboxylase in C(3) Plants

The role of phosphoenolpyruvate carboxylase in photosynthesis in the C(3) plant Nicotiana tabacum has been probed by measurement of the (13)C content of various materials. Whole leaf and purified ribulose bisphosphate carboxylase are within the range expected for C(3) plants. Aspartic acid purified following acid hydrolysis of this ribulose bisphosphate carboxylase is enriched in (13)C compared to whole protein. Carbons 1-3 of this aspartic acid are in the normal C(3) range, but carbon-4 (obtained by treatment of the aspartic acid with aspartate beta-decarboxylase) has an isotopic composition in the range expected for products of C(4) photosynthesis (-5 per thousand), and it appears that more than half of the aspartic acid is synthesized by phosphoenolpyruvate carboxylase using atmospheric CO(2)/HCO(3) (-). Thus, a primary role of phosphoenolpyruvate carboxylase in C(3) plants appears to be the anapleurotic synthesis of four-carbon acids.

Mesalamine did not prevent recurrent diverticulitis in phase 3 controlled trials

BACKGROUND & AIMS

No therapy has been proven to prevent the recurrence of diverticulitis. Mesalamine has shown efficacy in preventing relapse in inflammatory bowel disease, and there is preliminary evidence that it might be effective for diverticular disease. We investigated the efficacy of mesalamine in preventing recurrence of diverticulitis in 2 identical but separate phase 3, randomized, double-blind, placebo-controlled, multicenter trials (identical confirmatory trials were conducted for regulatory reasons).

METHODS

We evaluated the efficacy and safety of multimatrix mesalamine vs placebo in the prevention of recurrent diverticulitis in 590 (PREVENT1) and 592 (PREVENT2) adult patients with ≥1 episodes of acute diverticulitis in the previous 24 months that resolved without surgery. Patients received mesalamine (1.2 g, 2.4 g, or 4.8 g) or placebo once daily for 104 weeks. The primary end point was the proportion of recurrence-free patients at week 104. Diverticulitis recurrence was defined as surgical intervention at any time for diverticular disease or presence of computed tomography scan results demonstrating bowel wall thickening (>5 mm) and/or fat stranding consistent with diverticulitis. For a portion of the study, recurrence also required the presence of abdominal pain and an increase in white blood cells.

RESULTS

Mesalamine did not reduce the rate of diverticulitis recurrence at week 104. Among patients in PREVENT1, 53%-63% did not have disease recurrence, compared with 65% of those given placebo. Among patients in PREVENT2, 59%-69% of patients did not have disease recurrence, compared with 68% of those given placebo. Mesalamine did not reduce time to recurrence, and the proportions of patients requiring surgery were comparable among treatment groups. No new adverse events were identified with mesalamine administration.

CONCLUSIONS

Mesalamine was not superior to placebo in preventing recurrent diverticulitis. Mesalamine is not recommended for this indication. ClinicalTrials.gov ID: NCT00545740 and NCT00545103.

Complications of rubber band ligation of symptomatic internal hemorrhoids

In a prospective study, 512 patients undergoing hemorrhoidal band ligation over a seven-year period were followed up to focus on complications. Thirteen patients (2.5 percent) were hospitalized: six with delayed massive rectal bleeding, three with urinary retention, pain, and fever (one developed perianal abscess), and three others with severe pain due to prolapsed thrombotic hemorrhoids (one developed difficulty in urination). One patient developed perianal abscess and perianal fistula two months after ligation. Twenty-four patients (4.6 percent) suffered from minor complications: 11 patients had painful thrombosed hemorrhoids; five experienced slippage of bands; three had mild bleeding; two developed band-related mucosal ulcer; one experienced each time, after two subsequent ligations, priapism lasting several hours; and difficulty in urination and tender induration above the dentate line occurred in two other patients. Rubber band ligation is, in effect, a miniature hemorrhoidectomy and has been considered, until recent reports of fatalities associated with this procedure, as an effective, safe, and efficient method of treating symptomatic second-degree and third-degree hemorrhoids. We conclude that the ability to handle complications that occur secondary to the rubber band ligation and, thereby, prevent sepsis and the low rate of major complications in our study justify reliance on this method of treating symptomatic hemorrhoids.

Lung involvement and enzyme replacement therapy in Gaucher's disease

Symptomatic lung involvement in Gaucher's disease is relatively rare, being restricted to patients with other severe manifestations. We describe our experience in eight of 411 patients in our referral clinic, who presented with prominent pulmonary signs or symptoms. There were four adults and four children; all have been successfully treated with enzyme replacement therapy. Routine means of monitoring pulmonary status including clinical assessment, chest X-ray, pulmonary function tests, and high-resolution CT (HRCT) were used. Enzyme treatment resulted in decreased hepatosplenomegaly, improved haematological parameters, and increased well-being; There was decreased clubbing and decreased dyspnoea in some of the patients, although on radiology, lung pathology had not normalized. All four children showed improved respiratory compliance, with significant improvement of the radiological findings in one and unchanged disease in the others. Two adults showed improvement in oxygen saturation but worsening of pulmonary hypertension. On chest X-ray, both had increased interstitial markings; one had gradual progression of pulmonary artery accentuation and fine interstitial stable pattern on HRCT. The other two adults had no change in lung function or on chest X-ray, but on HRCT there was apparent improvement in one patient. There is great heterogeneity in presentation and response to enzyme therapy in patients with Gaucher's disease and symptomatic lung involvement. Clinically, some benefited significantly from enzyme therapy, but in contrast to the dramatic reduction in organomegaly, there was no normalization in pulmonary function or lung architecture.

Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease

OBJECTIVE

An assessment of oral symptoms and signs in patients with inflammatory bowel disease (IBD).

METHODS

Fifty-four patients with IBD, 34 with Crohn's disease (CD) and 20 with ulcerative colitis (UC) participated in the study. Forty-two patients without gastrointestinal disease or complaints attending the orthopedic clinic served as controls. Each patient completed a written questionnaire and was subjected to an oral examination.

RESULTS

The main findings of this study were the higher prevalence of halitosis (50% vs 10% P < 0.0008), nausea (30% vs 7%, P < 0.017) and reflux (regurgitation) (45% vs 17%, P < 0.017) in patients with UC, and nausea (50% vs 7%, P < 0.026), dry mouth and halitosis (29% vs 10%, P < 0.026) and vomiting (41% vs 5%, P = 0.01) in patients with CD, compared with controls. Patients with active CD had a higher prevalence of dry mouth, nausea and vomiting compared with controls (46, 69 and 54% vs 10, 7 and 5%, respectively, P < 0.001) and of reflux compared with non-active CD (46% vs 5%, P < 0.001). Patients with active UC had a higher prevalence of halitosis and regurgitation (50 and 60% vs 10 and 17%, P < 0.001) compared with controls.

CONCLUSIONS

The present study demonstrates increased frequency of oral signs and symptoms in patients with IBD. Patients with active CD had more oral signs compared with non-active CD patients. Manifestations such as nausea, vomiting, regurgitation and dry mouth may have detrimental effects on teeth and soft tissues of the oral cavity. Communication between gastroenterologists and dentists is imperative for success of the overall treatment of their patients.

Pulmonary function abnormalities in type I Gaucher disease

The purpose of this study was to determine the prevalence of pulmonary function and radiographic abnormalities among patients with type I Gaucher's disease, and to analyse the relationship between the pulmonary involvement and genotype and clinical severity score. All patients attending the Gaucher clinic at the Shaare Zedek Medical Center, Jerusalem, Israel, during the years 1992-1993 were prospectively evaluated. Each patient had pulmonary function tests, chest radiography, clinical assessment in terms of degree of organ involvement, and genotype analysis. Of the 95 patients included in the study (mean +/- SD age 29 +/- 15 yrs), 68% had some pulmonary function abnormalities, most commonly a reduced FRC and transfer coefficient for carbon monoxide (Kco), found in 45% and in 42% of the patients respectively. Total lung capacity (TLC) was reduced in 22% of the patients and forced expiratory flows in approximately one third of the patients. Signs of airtrapping (elevated residual volume (RV) or RV/TLC) were seen in 18% of the patients. Males had a higher incidence of reduced expiratory flow than females, (forced expiratory volume in one second (FEV1) was reduced in 36% of males vs 5% of females). Chest radiographic abnormalities were found in 17% of the patients, although only 4% had severe changes. Patients with abnormal pulmonary function had a significantly higher severity score index than those with normal pulmonary function tests. There was no association between abnormal pulmonary function and genotype or age. In conclusion, abnormal pulmonary function is common among type I Gaucher patients. Pulmonary function tests show airways obstruction, with reduced expiratory flows, reduction in lung volumes and alveolar-capillary diffusion abnormality. The rate of progression and the clinical significance need to be determined.

Carbon isotope effects on the decarboxylation of carboxylic acids. Comparison of the lactate oxidase reaction and the degradation of pyruvate by H2O2

The isotope effect at C-1 on the H2O2-catalysed decarboxylation of pyruvate (used as a model reaction for the enzymic reaction) increases between pH 3 and 10 from 1.0007 +/- 0.0004 to 1.0283 +/- 0.0014 (25 degrees C). This result indicates a change in the rate-determining step from formation of the tetrahedral intermediate to decarboxylation of this intermediate. Practically no isotope fractionation at C-1 (1.0011 +/- 0.0002, pH 6.0, 25 degrees C) is found in the lactate oxidase-catalysed decarboxylation of lactate, which is indicative for the existence of an irreversible O2-dependent step prior to the enzyme-catalysed decarboxylation. In addition, the result provides further evidence that dissociation of pyruvate and H2O2 from the enzyme can be excluded. The isotope effect at C-2 of lactate in the enzymic reaction (1.0048 +/- 0.0004) is attributed to the hydrogen transfer step from lactate to the coenzyme.

Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study

BACKGROUND AND STUDY AIMS

Outcomes following early colonoscopy in patients with acute diverticulitis have not previously been studied. The present study describes the effects of early colonoscopy in patients with acute diverticulitis.

PATIENTS AND METHODS

Consecutive patients hospitalized for acute diverticulitis were included in the study. In the first phase, patients with adjacent peridiverticular air or fluid on computed tomography (CT) were excluded. In the second phase of the study, only patients with free intraperitoneal air were excluded.

RESULTS

The study population consisted of 107 patients. During the first phase of the study, 49 patients were included; 10 were excluded because of peridiverticular air or fluid. The remaining 39 patients underwent uneventful colonoscopy. During the second phase of the study, 58 patients were included; four were excluded because of free air in the peritoneum. The remaining 54 patients underwent colonoscopy, and perforation of the sigmoid colon occurred in one patient with peridiverticular air. Complete colonoscopy to the cecum or to the obstructing tumor was achieved in 76 patients (81.7 %). A second colonoscopy performed 6 weeks later in 16 of the remaining 17 patients was successfully completed. Findings during the first colonoscopy were polyps in nine cases, polyp with infiltrating adenocarcinoma in one, obstructing adenocarcinoma in one, and a bone trapped in a diverticulum in another one. The latter two patients had a more protracted course and were clearly the ones who benefited most from the colonoscopy.

CONCLUSIONS

Early colonoscopy in patients with acute diverticulitis may alter the working diagnosis and be of therapeutic value. The rate of cecal intubation is lower and the perforation rate appears to be higher. A clear-cut indication therefore has to be evident clinically.

Autoimmune hepatitis in southern Israel: a 15-year multicenter study

OBJECTIVE

In this study we aimed to assess the incidence, prevalence and clinical outcomes of patients with autoimmune hepatitis (AIH) in southern Israel.

METHODS

Case-finding methods and population-based administrative data were used to evaluate the epidemiology and prognostic factors of AIH from 1995 to 2010.

RESULTS

During the study period, the average annual prevalence and incidence of AIH in southern Israel were 11.0/100000 and 0.67/100000, respectively. We identified 100 AIH cases with a mean age of 47.9 years, including 95 women and five men. Type 1 AIH was found in 77 cases, and liver fibrosis and cirrhosis were found in 73.4% and 22.3% of all patients who underwent liver biopsy. In all, 98 patients were treated with a combination of steroids and azathioprine or steroids alone (prednisone and azathioprine in 71, budesonide and azathioprine in 11, prednisone or budesonide alone in six and ten, respectively). Complete remission was recorded in 56 patients, whereas partial response or failure of treatment was noted in 42 patients. In multivariate analysis the independent predictors of remission were the degree of liver fibrosis (mild vs bridging fibrosis (F3) and cirrhosis [F4]) (P=0.003) and level of albumin (P=0.031). The estimated 1-year and 10-year survival for AIH were 96.5% and 89.7%, respectively.

CONCLUSIONS

The prevalence of AIH in Israel is quite similar to that of other European Caucasian populations, with a relatively long-term good prognosis, despite a low rate of response to immunosuppressive therapy.

Alcoholic Liver Disease: Role of Cytokines

The present review spans a broad spectrum of topics dealing with alcoholic liver disease (ALD), including clinical and translational research. It focuses on the role of the immune system and the signaling pathways of cytokines in the pathogenesis of ALD. An additional factor that contributes to the pathogenesis of ALD is lipopolysaccharide (LPS), which plays a central role in the induction of steatosis, inflammation, and fibrosis in the liver. LPS derived from the intestinal microbiota enters the portal circulation, and is recognized by macrophages (Kupffer cells) and hepatocytes. In individuals with ALD, excessive levels of LPS in the liver affect immune, parenchymal, and non-immune cells, which in turn release various inflammatory cytokines and recruit neutrophils and other inflammatory cells. In this review, we elucidate the mechanisms by which alcohol contributes to the activation of Kupffer cells and the inflammatory cascade. The role of the stellate cells in fibrogenesis is also discussed.

Alcoholic liver disease: Clinical and translational research

The present review spans a broad spectrum of topics dealing with alcoholic liver disease (ALD), including clinical research, translational research, pathogenesis and therapies. A special accent is placed on alcohol misuse, as alcohol is a legally commercialized and taxable product. Drinking alcohol, particularly from a young age, is a major health problem. Alcoholism is known to contribute to morbidity and mortality. A systematic literature search was performed in order to obtain updated data (2008-2015). The review is focused on genetic polymorphisms of alcohol metabolizing enzymes and the role of cytochrome p450 2E1 and iron in ALD. Alcohol-mediated hepatocarcinogenesis is also discussed in the presence or absence of co-morbidities such as viral hepatitis C as well as therapeutic the role of innate immunity in ALD-HCV. Moreover, emphasis was placed on alcohol and drug interactions, as well as liver transplantation for end-stage ALD. Finally, the time came to eradicate alcohol-induced liver and intestinal damage by using betaine.

Excellent outcome of Lamivudine treatment in patients with chronic renal failure and hepatitis B virus infection

Chronic hepatitis B virus (HBV) is associated with increased morbidity and mortality in patients with chronic renal failure (CRF) and renal transplant recipients. Lamivudine (3TC) has been shown to be a potent inhibitor of HBV replication. It appears to be safe and effective in patients with CRF, though experience is still limited. We describe 4 patients with CRF on hemodialysis who showed a rapid and full response to 3TC, administered for a median of 10 months. All patients had serum alanine transferase (ALT) levels 3 to 6 times the upper limit of normal prior to treatment, and different degrees of histologic inflammatory activity (Knodell score 4 to 8, median 6). All were serum HBsAg- and HBeAg-positive, with serum HBV DNA 1-3.9 x 107 copies/mL (median 1 x 107 copies/mL). Within 4 to 8 weeks of initiation of therapy, HBV DNA became undetectable and serum ALT normalized. Serum HBeAg disappeared in all 4 patients, with the emergence of anti-HBeAb in 3 of them. Three patients also lost HBsAg with the evolution of a protective anti-HBsAb titer. One patient has already undergone successful kidney transplantation with no evidence of HBV recurrence (serum HBV DNA negative) 16 months postoperatively. Although our study sample is small, these data suggest that 3TC can induce a complete biochemical, virological and serological response in patients with CRF and HBV infection. Its use may enable safe kidney transplantation in selected patients.

Assessment of the esophageal wall by endoscopic ultrasonography in patients with nutcracker esophagus

BACKGROUND

The correlation between the width of muscularis propria and esophageal pressure in patients with the nutcracker esophagus is unknown. We examined by endoscopic ultrasonography the width of the muscularis propria in patients with nutcracker esophagus.

METHODS

The width of muscularis propria was measured at the gastroesophageal junction and at the lower, middle, and upper esophagus in 18 patients and 10 control subjects.

RESULTS

Mean muscularis propria diameter in patients was 1.8 +/- 1.4, 1.5 +/- 1.2, 1.5 +/- 0.8, and 1.2 +/- 0.4 mm at the gastroesophageal junction, lower, middle, and upper esophagus. In the control group, the mean width was 1.2 +/- 0.3, 1.2 +/- 0.3, 1.1 +/- 0.3, and 0.9 +/- 0.1 mm, respectively. The difference was significant at the gastroesophageal junction and upper esophagus. The muscularis propria was wider than 3 mm in 30% of patients. There was no correlation between the site of the wide muscularis propria and the esophageal segment where high pressure was recorded. Length of disease, frequency of symptoms, and length of each symptomatic period did not correlate with the width of muscularis propria.

CONCLUSION

The muscularis propria is thickened in one third of patients with nutcracker esophagus. The extent and magnitude of this thickening do not correspond to the location and the magnitude of the manometric abnormality or clinical presentation.

Body positional effect on gas exchange in unilateral pleural effusion

The positional effect on gas exchange was studied in eight patients who had unilateral pleural fluid without clinical or radiologic evidence of parenchymal lung disease. In all eight patients, PaO2 values were higher when the lung with the pleural fluid was uppermost. The mean PaO2 in this position was 71.9 +/- 9.3 mm Hg (mean +/- SE) compared with 66.7 +/- 8.7 mm Hg in the lateral decubitus position with the pleural fluid lowermost. The mean difference in PaO2 between the two positions was 5.1 +/- mm Hg (p less than 0.005). Larger positional differences were found in the patients with the smallest pleural effusions. These results are probably due to perfusion of areas of unventilated lung, accentuated by gravity with a consequent increase in shunting. A large effusion also causes a decrease in perfusion, so that ventilation-perfusion mismatching is decreased and the positional effect on gas exchange diminished.

Helicobacter pylori: friend or foe?

Helicobacter pylori (H. pylori) is a Gram-negative spiral bacterium that is present in nearly half the world's population. It is the major cause of peptic ulcer disease and a recognized cause of gastric carcinoma. In addition, it is linked to non-ulcer dyspepsia, vitamin B12 deficiency, iron-deficient anemia and immune thrombocytopenic purpura. These conditions are indications for testing and treatment according to current guidelines. An additional indication according to the guidelines is "anyone with a fear of gastric cancer" which results in nearly every infected person being eligible for eradication treatment. There may be beneficial effects of H. pylori in humans, including protection from gastroesophageal reflux disease and esophageal adenocarcinoma. In addition, universal treatment will be extremely expensive (more than $32 billion in the United States), may expose the patients to adverse effects such as anaphylaxis and Clostridium difficile infection, as well as contributing to antibiotic resistance. There may also be an as yet uncertain effect on the fecal microbiome. There is a need for robust clinical data to assist in decision-making regarding treatment of H. pylori infection.

Some characteristics of the purinergic nervous system in normal and sensitized airway smooth muscle

Supramaximal electrical field stimulation was employed to produce biphasic response in segments of cervical and thoracic tracheas and in first generation of bronchi isolated from guinea pigs. This response consists of contraction (as measured by maximal active tension, ATmax) followed by relaxation (as measured by maximal active relaxation, ARmax). First, the effect of electrical stimulation was studied in relation to frequency and duration of impulse. Highest degree of relaxation (ARmax) was achieved with a frequency of stimulus of 40 pulses per sec for segments of trachea, and 60 pulses per sec for first generation bronchi, and with duration of pulse of 1.0 msec for segments of trachea, and 2.0-2.5 msec for bronchi, and with duration of pulse of 1.0 msec for segments of trachea, and 2.0-2.5 msec for bronchi. Secondly, mean length-tension relationship was determined. It was found that maximal relaxation (ARmax) occurred at 160 +/- 5% of Lmax in case of tracheal segments and 160 +/- 2% of Lmax for bronchial preparations. Using propranolol pretreatment (10(-4) M), which inhibited participation of adrenergic receptors in relaxation, it was determined that approximately 50% relaxation of airway smooth muscle of the normal guinea pig is mediated through the purinergic nervous system. Both tracheas and bronchi isolated from sensitized guinea pigs, chronically exposed to antigen, showed a significant decrease in overall relaxation (P less than 0.01). However, the per cent decrease in relaxation after propranolol was not different in sensitized animals than that found in controls. The data suggest that relaxation of segments of airways isolated from animals chronically exposed to antigen is decreased in consequence of alterations in both purinergic and adrenergic nervous systems.

Detection of pancreatic carcinoma: diagnostic value of K-ras mutations in circulating DNA from serum

Somatic activating mutations at codon 12 of the K-ras gene are present in the majority of exocrine pancreatic cancers and occur early in tumorgenesis. The aim of this study was to test the feasibility of using a mutated K-ras gene from the serum as a potential tumor marker for detection of exocrine pancreatic carcinoma. Codon 12 K-ras mutations were examined in DNA extracted from the sera of 20 patients with pancreatic carcinomas, six patients with chronic pancreatitis, and five healthy individuals. K-ras gene mutations at codon 12 were detected in the sera of 14 of 20 patients with pancreatic carcinoma and in none of the six patients with chronic pancreatitis, or in the five healthy controls. Elevation of either CA19-9 or K-ras mutation was detected in 19/20 patients. These results suggest that K-ras abnormalities in serum could be used as a potential tumor marker in patients with a pancreatic lesion. The absence of K-ras mutations in serum and presence of CA19-9 in the normal range make the diagnosis of pancreatic cancer unlikely.

Helicobacter pylori infection is associated with advanced colorectal neoplasia

OBJECTIVE

The aim of this article was to evaluate the prevalence of Helicobacter pylori infection in patients diagnosed with advanced colorectal neoplasia undergoing a colonoscopy compared to patients without neoplasia.

MATERIAL AND METHODS

This cross-sectional study investigated the association of neoplastic lesions diagnosed on colonoscopy with H. pylori infection in a consecutive series of subjects who had undergone a pancolonoscopy in a single academic medical center. All patients were tested by ELISA and the immunoblot technique for serum anti-H. pylori and CagA protein IgG antibodies. Multivariate analyses were adjusted for potential-relevant confounders, including age, sex, smoking, childhood socioeconomic status, and family history of colorectal cancer.

RESULTS

Two hundred and seventy-three patients were included in the study: 75% (84/112), diagnosed with neoplastic colorectal lesions and 48% (77/161) without neoplastic lesions, were found to be seropositive for H. pylori infection (p < 0.001). H. pylori infection was found in 66/77 (86 %) patients with advanced neoplasia, 18/35 (51%) patients with nonadvanced neoplasia, and 48% (77/161) patients without neoplasia (p < 0.001). In the adjusted analysis, H. pylori infection was found to be associated with advanced colorectal neoplasia (odds ratio, OR 9.57; 95% CI 4.31-21.2; p < 0.001) and CRC (OR 7.98;95% CI 3.16-20.16; p < 0.001). There was no association in patients who were CagA positive.

CONCLUSION

H. pylori infection is associated with the development of advanced colorectal neoplasia. More studies are needed to confirm our findings.

Oral administration of non-absorbable delayed release 6-mercaptopurine is locally active in the gut, exerts a systemic immune effect and alleviates Crohn's disease with low rate of side effects: results of double blind Phase II clinical trial

Therapy for Crohn's disease (CD) with thiopurines is limited by systemic side effects. A novel formulation of fixed-dose, delayed-release 6-mercaptopurine (DR-6MP) was developed, with local effect on the gut immune system and minimal absorption. The aim of this study was to evaluate the safety and efficacy of DR-6MP in patients with moderately severe CD compared to systemically delivered 6-mercaptopurine (Purinethol). Seventy CD patients were enrolled into a 12-week, double-blind controlled trial. The primary end-point was the percentage of subjects with clinical remission [Crohn's Disease Activity Index (CDAI) < 150] or clinical response (100-point CDAI reduction). Twenty-six (56·5%) and 13 (54·2%) subjects from the DR-6MP and Purinethol cohorts, respectively, completed the study. DR-6MP had similar efficacy to Purinethol following 12 weeks of treatment. However, the time to maximal clinical response was 8 weeks for DR-6MP versus 12 weeks for Purinethol. A higher proportion of patients on DR-6MP showed clinical remission at week 8. A greater improvement in Inflammatory Bowel Disease Questionnaire (IBDQ) score was noted in the DR-6MP group. DR-6MP led to a decrease of CD62(+) expression on T cells, implying a reduction of lymphocyte adhesion to site of inflammation. DR-6MP was safer than Purinethol, with significantly fewer adverse events (AEs). There was no evidence of drug-induced leucopenia in the DR-6MP group; the proportion of subjects who developed hepatotoxicity was lower for the DR-6MP. Non-absorbable DR-6MP is safe and biologically active in the gut. It is clinically effective, exerting a systemic immune response with low systemic bioavailability and a low incidence of side effects.

Disseminated intravascular coagulation and hypopotassemia associated with blast lung injury

Forty six people were injured by a large explosive charge detonated in a Jerusalem bus. Four were killed instantaneously and 22 needed hospital care. We describe our experience in five patients with blast lung injury (BLI), all of whom survived in spite of severe respiratory failure requiring mechanical ventilation. Disseminated intravascular clotting (DIC) developed in three of the five patients and significant hypopotassemia ranging from 2.2 to 2.9 mEq/L in four. These two complications have not been previously described in association with BLI. Both DIC and hypopotassemia responded to replacement therapy. Vigorous treatment of respiratory failure, early recognition, and prompt correction of hemostatic and electrolyte abnormalities may have contributed to the avoidance of fatalities among the five patients with severe blast injury.

Five years of fecal microbiota transplantation - an update of the Israeli experience

AIM

To evaluate and describe the efficacy of fecal microbiota transplantation (FMT) for Clostridium difficile infection (CDI) in a national Israeli cohort.

METHODS

All patients who received FMT for recurrent (recurrence within 8 wk of the previous treatment) or refractory CDI from 2013 through 2017 in all the five medical centers in Israel currently performing FMT were included. Stool donors were screened according to the Israeli Ministry of Health guidelines. Clinical and laboratory data of patients were collected from patients’ medical files, and they included indications for FMT, risk factors for CDI and disease severity. Primary outcome was FMT success (at least 2 mo free of CDI-related diarrhea post-FMT). Secondary outcomes included initial response to FMT (cessation of diarrhea within 7 d) and recurrence at 6 mo.

RESULTS

There were 111 FMTs for CDI, with a median age of 70 years [interquartile range (IQR): 53-82], and 42% (47) males. Fifty patients (45%) were treated via the lower gastrointestinal (LGI, represented only by colonoscopy) route, 37 (33%) via capsules, and 24 (22%) via the upper gastrointestinal (UGI) route. The overall success rate was 87.4% (97 patients), with no significant difference between routes of administration (P = 0.338). In the univariant analysis, FMT success correlated with milder disease (P = 0.01), ambulatory setting (P < 0.05) and lower Charlson comorbidity score (P < 0.05). In the multivariant analysis, only severe CDI [odd ratio (OR) = 0.14, P < 0.05] and inpatient FMT (OR = 0.19, P < 0.05) were each independently inversely related to FMT success. There were 35 (32%) patients younger than 60 years of age, and 14 (40%) of them had a background of inflammatory bowel disease.

CONCLUSION

FMT is a safe and effective treatment for CDI, with capsules emerging as a successful and well-tolerated route. Severe CDI is less likely to respond to FMT.