Hemostatic changes before and during electrophysiologic study and radiofrequency catheter ablation

We sought to investigate specific hemostasis activation markers during electrophysiologic study (EPS) with consequent radiofrequency catheter ablation (RFA). Sixty patients were studied prospectively during routine EPS with RFA for paroxysmal supraventricular tachycardia. Blood samples were drawn before the insertion of venous sheaths (T0), at the end of EPS (T1), and 30 min after completion of RFA (T2). To study coagulation and fibrinolytic and platelet activity, we measured concentrations of thrombin-antithrombin III (TAT), D-dimers (DD), plasminogen activator inhibitor type 1 (PAI-1), tissue-type plasminogen activator (t-PA), and circulating platelet aggregates. The results are expressed as median and show 95% confidence levels. Levels of DD increased from 0.24 mg/L at T0 to 0.37 mg/L at T1 (P < 0.001) and to 0.59 mg/L at T2 (P < 0.001). TAT levels increased from 5.29 μg/L at T0 to 35.80 μg/L at T1 (P < 0.001) and decreased to 26.30 μg/L at T2 (P < 0.001). PAI-1 concentration decreased from 30.10 μg/L at T0 to 26.4 μg/L at T1 (P < 0.001). t-PA at T2 increased to 5.10 μg/L from 4.75 μg/L at T1 (P = 0.001). No other differences between corresponding medians were statistically significant (P > 0.05). We found that concentrations of DD at T2 versus T1 depended on the number of radiofrequency energy applications (r (S) = 0.387; P = 0.002). Marked platelet activation was observed from the start of the procedure, without changes during the procedure.

Hiatal hernia and Barrett's oesophagus impact on symptoms occurrence and complications

The aim of the study was to evaluate the influence of sliding hiatal hernia over the Barrett's oesophagus, including symptoms rate and complications.

METHODS

A total of 520 (4.6%) cases of Barrett's oesophagus were found out of 18.276 upper gastrointestinal endoscopies, performed in 11.276 patients at a single tertiary centre in a period from 1994 to 2004.

RESULTS

Sliding hiatal hernia was found in 58% of patients with Barrett's oesophagus, more frequently in men (60%). The association between hernia and some complications of Barrett's oesophagus was significant (94% of Barrett's ulcer, 77% of low-grade dysplasia with p < 0.01). However, there was no significant association with adenocarcinoma (54%; p > 0.05). The other complications of Barrett's oesophagus (i.e. bleeding, stenosis, high-grade dysplasia) were identified in small number (less than 10), so they were not evaluated statistically. Association between the presence of hiatal hernia and occurrence of symptoms (reflux symptoms, dysphagia, odynophagia, dyspeptic and other symptoms) was significant with p < 0.01.

CONCLUSIONS

Our study suggests that sliding hiatal hernia may play a significant role as a pathophysiologic factor in Barrett's oesophagus. Complications rate of Barrett's oesophagus were not equally frequent in particular cases with hiatal hernia. The occurrence of symptoms is getting more pronounced in those with sliding hiatal hernia.

[Achieving Bcl-2/IgH negativity in peripheral blood/bone marrow after therapy implies better prognosis for patients with follicular lymphoma]

Bcl-2/IgH rearrangement is a characteristic molecular rearrangement in patients with follicular lymphoma (FL), yet its prognostic significance is still unclear.

OBJECTIVE

Evaluation of the implications of achieving Bcl-2/IgH negativity for the prognosis of FL patients. Twenty seven patients (54%) were receiving only chemotherapy (CHT), 23 patients (46%) were receiving chemotherapy combined with monoclonal antibody anti/CD20, rituximab (R-CHT).

RESULTS

Molecular genetic remission was achieved in 7 out of 11 patients (64%) after R-CHT, and only in 2 out of 14 patients (14%) after CHT- this difference was statistically significant (p = 0.037). 4 weekly doses of rituximab were administered in a sequence to 17 out of 27 patients who had received only chemotherapy and failed to achieve complete remission. 12 out of 17 patients (71%) on this therapy were Bcl-2/IgH positive prior to treatment. 7 out of 12 (58 %) patients were no longer Bcl-2/IgH positive in a check performed after one month; the remaining 2 out of 5 patients had a negative Bcl-2/IgH record for the interval of 3 months (1 patient) or 6 (1 patient) months, respectively. The following factors were associated with the achievement of Bcl-2/IgH negativity at any point during the treatment: age < 65 years (p = 0.02) and performance status 0 + 1 according to WHO at baseline (p = 0.02). Patients who were Bcl-2/IgH negative after treatment had a lower recurrence/progression risk rate than the Bcl-2/IgH positive group of patients, i.e. 27% vs. 75% (p = 0.03), and a higher chance for progression-free survival, i.e. 81% vs. 38% (p = 0.004), event-free survival, i.e. 74% vs. 38% (p = 0.01), and overall survival, i.e. 87% vs. 74% (p = 0.05) at 2 years.

CONCLUSION

In our experience, achieving Bcl-2/IgH negativity after follicular lymphoma therapy implies a better prognosis.

[Examination of gastric emptying rate by means of 13C-octanoic acid breath test. Methods of the test for adults and results of the investigation of healthy volunteers]

BACKGROUND

13C-octanoic acid breath test (13C-OABT) is a simple, safe and non-invasive technique for measuring gastric emptying. However, the method has not been standardized yet. Aim of the study was to work up, introduce and evaluate our own method of the 13C-OABT for adults.

METHODS AND RESULTS

Ten healthy volunteers entered the study (5 men, 5 women, mean age 32 years, 50 % Helicobacter pylori positive). Standard test meals (with 100 mg 13C-sodium octanoate) were used three times within 3 weeks. The same solid meal (1,178 kJ) for Tests 1 and 2 contained scrambled egg (+ 3 g oil), white bread (40 g), butter (10 g) and distilled water (200 ml). Semi-solid meal (1,020 kJ) for Test 3 contained milk pudding (200 g) and distilled water (200 ml). Duplicate breath samples were obtained before and every 15 minutes after eating the test meal during 255 minutes. Altogether 1,080 breath samples were analysed twice (isotope ratio mass spectrometry, AP2003 Analytical Precision, UK). To assess the half-life of elimination (t1/2 E), we modelled the process of elimination with the incomplete gamma-function, which has a convenient form for the empiric plotting of breath test data. Mean t1/2E was 136+/-10 minutes (Test 1), 134+/-14 (Test 2) and 123+/-16 minutes (Test 3). Clinical reproducibility of 13C-OABT in particular persons was 98.2% (18 breath samples series), 90.8 % (15 samples) and 87.1% (9 breath samples series). There was a significant correlation between Test 1 and Test 2 results (r=0.887, p<0.0001). Mean difference of duplicate breath sample analysis was 1.460 % (in 540 pairs), mean baseline one-day analysis difference was 0.0982 (99.9274% accuracy). In healthy volunteers, normal range of t1/2E is 110-160 minutes for solids and 91-155 minutes for semisolid test meal. Using our own computed mean time of intermediate metabolism of 13C-octanoic acid (76.5+/-7.5 minutes), gastric emptying half-time is 33.5-83.5 minutes for solids and 14.5-78.5 minutes for semisolid test meal in healthy volunteers.

CONCLUSIONS

The 13C-OABT is accurate non-invasive method for gastric emptying measurement.

A randomized, double blind comparative study of prophylactic parenteral nutritional support with or without glutamine in autologous stem cell transplantation for hematological malignancies -- three years' follow-up

Forty-four adult autologous transplant patients with hematological malignancies were randomized to receive either prophylactic parenteral nutrition PN (P group), or PN given ad hoc (C group). In each group, they were further randomized to receive standard PN (B group), or PN with 0.5 g glutamine/kg as L-Ala-L-Gln (A group). The overall survival (OS), disease-free survival (DFS) and event-free survival (EFS) in groups C vs. P and A vs. B were compared during follow-up with median 38 months. The final outcome rates in C/P/A/B groups, respectively (OS 65/81/63/85%, EFS 45/53/33/65% and DFS 56/50/35/77%), were not significantly different, apart from A < B in DFS rate (p=0.03, Fisher's exact test). Also in survival analysis (logrank test), no significant difference between groups C and P was found but generally worse parameters were observed for A vs. B group: for DFS (p=0.04) and EFS (p=0.01) the difference was significant, and for OS (p=0.09) it was borderline. In the three years' follow-up, no clinically useful benefit of prophylactic PN in autologous transplant patients was proven. Also, glutamine supplementation was not helpful, and was even connected with apparently worse long-term outcome.

[The activation of haemostasis during radiofrequency catheter ablation]

The aim of the study was to investigate chosen haemostasis activation markers during electrophysiologic study (EPS) with consequent radiofrequency catheter ablation (RFA). Sixty-three patients were studied prospectively. Indications for EPS and RFA were supraventricular tachycardias with the arrhythmogenic substrate located in the right atrium. Blood samples were drawn 24 hours before the procedure (T -1), at the beginning of the procedure (T0), at the end of EPS (T1), 30 minutes after completion of RFA (T2), and 24 hours after the procedure (T3). To study coagulation, fibrinolytic and platelet activation were measured concentrations of thrombin-antithrombin III (TAT), D-dimers (DD), platelet count and parameters, and circulating platelet aggregates (CPAi). During the EPS and RFA, TAT levels increased from the baseline 5.03 +/- 2.53 microg/l (T -1) to 12.90 +/- 12.83 microg/l at T0 (p < 0.001) to 36.07 +/- 15.59 microg/l at T1 (p < 0.001) and decreased to 28.85 +/- 13.14 microg/l at T2 (p < 0.001). Levels of DD increased from 0.30 +/- 0.20 mg/l at T0 to 0.44 +/- 0.25 mg/l at T1 (p < 0.001) and to 0.87 +/- 0.74 mg/l at T2 (p < 0.001). The number of platelets was significantly decreased (-13.7%) before and during the procedure (T -1 vs. T3; p < 0.001). Marked platelet activation (CPAi 0.62 +/- 0.32) was observed before the procedure opposite to the physiological values (CPAi 1.0 +/- 0.1), without changes during the procedure (CPAi at T2 0.69 +/- 0.23). Our results confirmed activation of several haemostasis parameters during EPS and RFA, and support eligibility of the antithrombotic prevention in patients indicated for EPS and RFA.

DNA topoisomerase II-alpha in pulmonary carcinoid tumors

Fifty-four pulmonary carcinoid tumors of surgically treated patients were diagnosed according to modified Arrigoni histological criteria (WHO 1999). Forty-seven typical (TC) and seven atypical carcinoids (AC) formed the basic groups. Four subgroups were selected from the TCs and consisted of cases with higher tumor size (T2) or those associated with nodal involvement (N1), tumor satellites, and tumorlets. Subgroup tumors were regarded as affections with possible increased proliferation potential. The proliferate activity was examined immunohistochemically by topoisomerase II-alpha (clone SWT3D1) on paraffin material and calculated by the number of positive nuclei per 10 HPF. The topoisomerase expression was found to be statistically different in both principal groups made up of typical and atypical carcinoids with a mean value of 49 and 135 positive nuclei per 10 high power field in TC and AC, respectively. The remaining subgroups of the TCs associated with examined characteristics (larger tumor diameter, metastases, satellites, tumorlets) were not found to be statistically different. The topoisomerase II-alpha is a marker giving valuable information about the diagnosis of pulmonary typical and atypical carcinoids.

Environmental exposure of small children to polycyclic aromatic hydrocarbons

OBJECTIVES

The aim of the study was to assess the intake (by various routes of exposure) of polycyclic aromatic hydrocarbons (PAH) by children living in a Czech city, and its effect on excretion of 1-hydroxypyrene (1-OHP) in summer and winter periods.

METHODS

Four groups of children (3-6 years old) were chosen: (1) two groups from a kindergarten situated in the city center with a higher traffic density ("polluted" area); (2) two groups from a kindergarten situated in a green zone of the same city ("non-polluted" area). Food consumption was recorded in all children and PAH intake from foodstuffs was estimated. Ambient air samples were collected from the playground and inside the kindergartens. Soil samples were collected too. Morning and evening urine samples were collected during sampling days.

RESULTS

In both seasons, the mean outdoor total PAH concentration (sum of 12 individual PAH) in the -polluted" area was approximately three-times higher than that in the "non-polluted" area. Indoor concentration in the "polluted" area was more than six-times higher than that in the "non-polluted" area in summer, and almost three-times higher in winter. The same trend was observed for pyrene and for the sum of carcinogenic PAH. The contribution to the total pyrene absorbed dose from food consumption was much more important than that from inhalation and from ingestion of soil dust. Significantly higher urinary concentrations of 1-OHP (evening samples) were found in children from the "polluted" kindergarten in both seasons. The number of significant relationships between 1-OHP and pyrene absorbed dose was weak.

CONCLUSIONS

Food seems to be the main source of total pyrene and total PAH intake in small children, even under relatively higher air PAH exposure in the city. Estimated pyrene ingestion from soil had a negligible contribution to the total pyrene absorbed dose. Urinary 1-OHP seems to be an uncertain (non-sensitive) marker of the environmental inhalation exposure to pyrene (PAH) if the pollution of air by pyrene (PAH) is not excessive and the pyrene (PAH) dose by this route is much less than by ingestion. Usefulness of the urinary 1-OHP as an indicator of overall environmental exposure to PAH needs further investigation.

Value of Doppler sonography in revealing transjugular intrahepatic portosystemic shunt malfunction: a 5-year experience in 216 patients

OBJECTIVE

The purpose of the study was to evaluate the long-term clinical efficacy of Doppler sonography in revealing failure of transjugular intrahepatic portosystemic shunts (TIPS).

SUBJECTS AND METHODS

During a 5-year period, 1192 Doppler examinations were performed in 216 patients with TIPS. No regular follow-up shunt venography was performed. Doppler examinations were retrospectively compared with the results of shunt revisions. Sonograms with negative findings were compared with the patients' clinical status so that the number of false-negative sonographic findings leading to an episode of shunt failure (recurrence of gastrointestinal bleeding or ascites) could be ascertained. Sonographic parameters assessed included diameter, velocity, flow volume, and congestion index of the portal vein; and shunt velocities.

RESULTS

Doppler sonography revealed shunt occlusion in 25 of 26 angiographically proven cases (sensitivity, 96%). The combination of velocity criteria (peak intrashunt velocity > or =250 cm/sec, maximum velocity in the portal third of the shunt < or =50 cm/sec, or maximum portal vein velocity less than or equal to two thirds of the baseline value) revealed shunt stenosis in 103 of 110 cases (sensitivity, 94%). Doppler sonography missed a significant shunt stenosis that led to an episode of gastrointestinal bleeding or ascites recurrence in only seven cases. The congestion index of the portal vein showed significant differences between patent and malfunctioning shunts (p < 0.001).

CONCLUSION

Doppler sonography is an effective primary imaging method for long-term follow-up of patients with TIPS.

Assessment of multipathway exposure of small children to PAH

The aim of study was to assess the uptake of polycyclic aromatic hydrocarbons (PAH) by children living in a city and its effect on 1-hydroxypyrene (1-OHP) excretion. Two groups of children (n=11 and 13; 3-6 years old) were chosen: (1) a group from a kindergarten situated near a road with a high traffic density ('polluted' area); (2) a group from a kindergarten situated in a green zone ('non polluted' area). Food consumption was recorded in all children and PAH uptake from foodstuffs was estimated. Ambient air samples were collected on the playground and indoor of kindergartens during 3 days in summer 1997. Soil samples were collected on the playground. Urine samples were collected in the morning and in the evening. Mean outdoor total PAH concentration (sum of 12 individual PAH) in 'polluted' area was 12 times higher than that in 'non polluted' area (22.9 vs. 1.9 ng/m(3)). However, indoor concentrations were similar (3.0 vs. 2.1 ng/m(3)). The same trend was observed for pyrene concentrations. The contribution to the total pyrene absorbed dose from food consumption (estimated daily absorbed dose of 167 and 186 ng, respectively, in 'polluted' and 'non polluted' area) was much more important than that from inhalation (8.4 and 5.4 ng, respectively) in both areas. The estimated daily absorbed doses of pyrene from the soil were 0.061 and 0.104 ng in 'polluted' and 'non polluted' kindergarten, respectively, which correspond to 0.032 and 0.059% of the total absorbed dose. Higher urinary concentrations of 1-OHP were found in children from 'polluted' kindergarten. In conclusion, the food seems to be a main source of the total pyrene and total PAH uptake in small children, even under a relative high PAH air exposure in the city. Pyrene concentration in soil had a negligible contribution to the total pyrene absorbed dose. Usefulness of the urinary 1-OHP as an indicator of the environmental exposure to PAH needs further research.

[Proliferative activity in pulmonary carcinoids]

AIM

On the basis of known Ki-67 dependence on tumor malignancy in some lesions, we compared this marker expression quantitatively in pulmonary typical and atypical carcinoid tumors and attempted to predict their biological behavior especially in cases associated with tumorous lymphadenopathy, satellites, and carcinoid tumorlets.

METHOD

Using material from surgically treated patients, we examined 54 cases of pulmonary carcinoids divided into five groups. 1. Forty-two typical carcinoids (TC), 2. Twelve atypical carcinoids (AC) diagnosed according to modified Arrigoni's criteria (Travis et al., 1998), 3. Thirty-two TC without metastases, satellites, and tumorlets (M, S, T), 4. Eight AC without M, S, T, and 5. Fourteen TC and AC associated with M, S, T. Groups 3, 4, and 5 were formed of cases selected from group 1 and 2. The proliferate activity was evaluated by Ki-67 (MIB-1, Immunotech France, 1:25). Its nuclear labeling was counted in more than 50 HPF and calculated as a number of positive nuclei in 10 HPF. The Fisher exact test was used for statistical analysis.

RESULTS

The Ki-67 nuclear expression was found in 19 (45%) out of 42 TC and in 9 (75%) out of 12 AC. In the set of TC without metastases (M, S, T), the Ki-67 positive labeling was found in 14 (44%) out of 32 cases (group III) and in six (75%) out of eight AC (group IV). In all TC and AC tumors with M, S, T (group V), the Ki-67 expression was encountered in 8 (57%) out of 14 cases. The Fisher exact test showed no significant difference between all examined groups.

CONCLUSION

No statistically significant difference was found in Ki-67 expression in pulmonary typical and atypical carcinoids. It appears to be a factor which can not be used for tumor prognosis prediction or adjuvant therapy indication in surgically treated patients.

[Satellite cells in pulmonary carcinoid tumorlets and carcinoids]

Pulmonary tissue of twenty-four patients with carcinoid tumorlets and twenty-three typical carcinoid tumors was studied immunohistochemically for stellate-shaped S-100 protein positive (sustentacular) cells. Sustentacular cells (SCs) have been calculated per 10,000 tumorlet or carcinoid elements. The presence of SCs was proved in 18 subjects (75%) of all examined tumorlet cases with quantitative frequency between 13 and 196 SCs per 10,000 tumorlet cells. These elements were also found in 18 carcinoid tumors (79%) of all 23 investigated cases with quantitative frequency between 5 and 927 SCs per 10,000 carcinoid cells. The cluster analysis showed two separate clusters in both groups of lesions with strikingly high frequency of SCs, i.e., from 66 up to 196 SCs/10,000 tumorlet elements and from 138 up to 923 CSs/10.000 carcinoid cells, respectively. SCs may not be used as an indicator of biological behaviour of pulmonary neuroendocrine tumors for their a broad frequency spectrum in examined benign lesions, i.e. tumorlets and typical carcinoid tumors.

S-100 protein positive (sustentacular) cells in pulmonary carcinoid tumorlets: a quantitative study of 24 cases

Stellate-shaped S-100 protein positive sustentacular cells (SCs) appear to correlate inversely with the degree of tumor malignancy in some neuroendocrine tumors. Therefore, the SCs have been investigated in carcinoid pulmonary tumorlets and subsequently examined quantitatively in order to provide a basis for estimation of this phenomenon in tumorlet related lesions, especially carcinoids and neuroendocrine carcinomas. Pulmonary tissue from twenty-four patients with carcinoid tumorlets was studied immunohistochemically for S-100 protein positive SCs together with glial fibrillary acidic protein, actin, desmin, vimentin and cytokeratins. Tumorlet SCs were calculated per 10,000 tumorlet elements. The presence of SCs was proven in 18 subjects (75%) of all examined cases with quantitative frequency between 13 and 196 SCs per 10,000 tumorlet elements. The histogram showed three separate clusters of cases. Cluster 2 and cluster 3 with strikingly high frequency of SCs, i.e. from 66 up to 196 SCs per 10,000 tumorlet cells, may represent the biphasic differentiation potential of tumorlet elements. The mentioned lesions could be regarded as the possible precursors of pulmonary paragangliomas or paraganglioid carcinoids.