Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) is the first choice endoscopic technique for small-bowel visualization. However, preparation and handling of the double-balloon enteroscope is complex. Recently, a single-balloon enteroscopy (SBE) system has been introduced as being a simplified, less-complex balloon-assisted enteroscopy system.

PATIENTS AND METHODS

This study was a randomized international multicenter trial comparing two balloon-assisted enteroscopy systems: DBE vs. SBE. Consecutive patients referred for balloon-assisted enteroscopy were randomized to either DBE or SBE. Patients were blinded with regard to the type of instrument used. The primary study outcome was oral insertion depth. Secondary outcomes included complete small-bowel visualization, anal insertion depth, patient discomfort, and adverse events. Patient discomfort during and after the procedure was scored using a visual analog scale.

RESULTS

A total of 130 patients were included over 12 months: 65 with DBE and 65 with the SBE technique. Patient and procedure characteristics were comparable between the two groups. Mean oral intubation depth was 253 cm with DBE and 258 cm with SBE, showing noninferiority of SBE vs. DBE. Complete visualization of the small bowel was achieved in 18 % and 11 % of procedures in the DBE and SBE groups, respectively. Mean anal intubation depth was 107 cm in the DBE group and 118 cm in the SBE group. Diagnostic yield and mean pain scores during and after the procedures were similar in the two groups. No adverse events were observed during or after the examinations.

CONCLUSIONS

This head-to-head comparison study shows that DBE and SBE have a comparable performance and diagnostic yield for evaluation of the small bowel.

Overlapping functions of lysosomal acid phosphatase (LAP) and tartrate-resistant acid phosphatase (Acp5) revealed by doubly deficient mice

To date, two lysosomal acid phosphatases are known to be expressed in cells of the monocyte/phagocyte lineage: the ubiquitously expressed lysosomal acid phosphatase (LAP) and the tartrate-resistant acid phosphatase-type 5 (Acp5). Deficiency of either acid phosphatase results in relatively mild phenotypes, suggesting that these enzymes may be capable of mutual complementation. This prompted us to generate LAP/Acp5 doubly deficient mice. LAP/Acp5 doubly deficient mice are viable and fertile but display marked alterations in soft and mineralised tissues. They are characterised by a progressive hepatosplenomegaly, gait disturbances and exaggerated foreshortening of long bones. Histologically, these animals are distinguished by an excessive lysosomal storage in macrophages of the liver, spleen, bone marrow, kidney and by altered growth plates. Microscopic analyses showed an accumulation of osteopontin adjacent to actively resorbing osteoclasts of Acp5- and LAP/Acp5-deficient mice. In osteoclasts of phosphatase-deficient mice, vacuoles were frequently found which contained fine filamentous material. The vacuoles in Acp5- and LAP/Acp5 doubly-deficient osteoclasts also contained crystallite-like features, as well as osteopontin, suggesting that Acp5 is important for processing of this protein. This is further supported by biochemical analyses that demonstrate strongly reduced dephosphorylation of osteopontin incubated with LAP/Acp5-deficient bone extracts. Fibroblasts derived from LAP/Acp5 deficient embryos were still able to dephosphorylate mannose 6-phosphate residues of endocytosed arylsulfatase A. We conclude that for several substrates LAP and Acp5 can substitute for each other and that these acid phosphatases are essential for processing of non-collagenous proteins, including osteopontin, by osteoclasts.

Alternative mechanisms for trafficking of lysosomal enzymes in mannose 6-phosphate receptor-deficient mice are cell type-specific

Viable mice nullizygous in genes encoding the 300 kDa and the 46 kDa mannose 6-phosphate receptors (MPR 300 and MPR 46) and the insulin like growth factor II (IGF II) were generated to study the trafficking of lysosomal enzymes in the absence of MPRs. The mice have an I-cell disease-like phenotype, with increase of lysosomal enzymes in serum and normal activities in tissues. Surprisingly, the ability of MPR-deficient cells to transport newly synthesized lysosomal enzymes to lysosomes and the underlying mechanisms were found to depend on the cell type. MPR-deficient thymocytes target newly synthesized cathepsin D to lysosomes via an intracellular route. In contrast, hepatocytes and fibroblasts secrete newly synthesized cathepsin D. In fibroblasts recapture of secreted lysosomal enzymes, including that of cathepsin D, is limited and results in lysosomal storage, both in vivo and in vitro, whereas recapture by hepatocytes is remarkably effective in vivo and can result in lysosomal enzyme levels even above normal.

Monitoring of Usutu virus activity and spread by using dead bird surveillance in Austria, 2003-2005

Usutu virus has been causing avian mortality in Austria since its emergence in 2001. Between 2003 and 2005 a total of 504 dead birds were examined by reverse-transcriptase polymerase chain reaction and immunohistochemistry for the presence of Usutu virus nucleic acid and antigen, respectively. In 2003, 92 birds (out of 177 birds) belonging to five different species were positive, while in 2004, only 11 (of 224) birds, and in 2005, 4 (of 103) birds proved positive, all of which were blackbirds (Turdus merula). Within the surveillance period the virus had spread from its initial area of emergence and circulation, the surroundings of Vienna, to large areas of the federal states of Lower Austria, Burgenland and Styria. However, the absolute numbers of Usutu virus associated avian deaths declined significantly during the course of the years. In addition, the proportion of birds with low amounts of virus in their tissues increased continuously, which may indicate developing herd immunity.

Post-ERCP pancreatitis in 2364 ERCP procedures: is intraductal ultrasonography another risk factor?

BACKGROUND AND STUDY AIMS

Acute pancreatitis is considered a relevant major complication following endoscopic retrograde cholangiopancreatography (ERCP); according to literature data, the incidence varies between 1.5 % and 17 %. In the present study, we aimed to identify potentially new, hitherto unknown risk factors for post-ERCP pancreatitis.

PATIENTS AND METHODS

A total of 2364 ERCP procedures performed in 1275 patients during the years 2004 - 2008 were included in the study. Post-ERCP pancreatitis was defined as acute abdominal pain within 48 hours following ERCP with at least 3-fold elevated levels of serum lipase and a requirement for analgesic drugs for at least 24 hours. The severity of the pancreatitis was determined using the Imrie score.

RESULTS

In our cohort study a total of 54 different patients (2.3 %) developed post-ERCP pancreatitis. In 50 of these patients (92.6 %) the pancreatitis was mild; in 54 (7.4 %) it was severe. Patients with post-ERCP pancreatitis had highly significantly lower bilirubin levels than patients who did not have post-ERCP pancreatitis ( P < 0.001). Length of hospital stay, duration of analgesics, and need for analgesic drugs were significantly higher in patients suffering from severe pancreatitis ( P ≤ 0.01). In multivariate analysis, among other, already well-described risk factors we identified intraductal ultrasonography as another risk factor for post-ERCP pancreatitis, with a hazard ratio of 2.41 ( P = 0.004).

CONCLUSIONS

According to our retrospective data, intraductal ultrasonography seems to be another independent risk factor for developing post-ERCP pancreatitis, which needs to be further elucidated in prospective studies.

Familial glomerulonephropathy in the Bullmastiff

Glomerular disease was diagnosed by histopathologic examination in 11 related Bullmastiff dogs, and clinical and laboratory data were collected retrospectively. Four female and seven male dogs between the ages of 2.5 and 11 years were affected. Clinical signs, including lethargy and anorexia, were nonspecific and occurred shortly before death or euthanasia. In five affected dogs serial blood samples were obtained, and dramatically elevated blood urea nitrogen and creatinine levels were demonstrated up to 2.75 years before death. Protein-creatinine ratios were elevated in six of six dogs and were above normal 3.5 years before death in one dog. The kidneys appeared grossly normal to slightly smaller than normal at necropsy. Histologic abnormalities of the kidneys were consistent with chronic glomerulonephropathy with sclerosis. Examination of the pedigrees of related affected dogs yielded evidence supporting an autosomal recessive mode of inheritance.

Papillary mesothelioma of the peritoneum in the absence of asbestos exposure

BACKGROUND

Malignant mesothelioma of the peritoneum is a very rare neoplasm, commonly associated with asbestos exposure and often rapidly fatal. Well Differentiated Papillary Mesothelioma of the Peritoneum (WDPMP) is regarded as a less aggressive variety of the tumor. Progressive ascites is often the only clinical manifestation of the disease and differentiation of WDPMP from benign mesothelial hyperplasia or adenocarcinoma is difficult.

PATIENTS AND METHODS

Here we report the case of a 45-year-old patient who presented with ascites but without evidence of portal hypertension, liver disease or abdominal malignancy. On diagnostic laparoscopy small tumor nodules were found to cover the parietal peritoneum and the greater omentum and histopathologically corresponded to papillary mesothelial hyperplasia with minimal nuclear atypia. Histochemically biopsies were positive for Calretinin, Cytokeratins and Epithelial Membrane Antigen (EMA). Based on these findings the diagnosis of WDPMP was made and the patient was closely followed without primary cytostatic therapy.

CONCLUSIONS

Progressive ascites was the only clinical symptom in this patient, while liver disease, portal hypertension and gastrointestinal malignancies were ruled out by clinical, laboratory and imaging techniques. Laparoscopic biopsy revealed WDPMP to be the underlying disease. Immunocytochemistry is required to establish the diagnosis of this rare malignant disorder which is even more uncommon in the absence of a history of asbestos exposure. Due to the indolent course of WDPMP therapy should only be initiated when signs of rapid tumor progression become apparent.

Factors influencing morbidity and mortality after cranial meningioma surgery--a multivariate analysis

In a retrospective analysis 385 patients with a histologically defined cranial meningioma were studied to analyze the impact of characteristic factors on morbidity and mortality after modern cranial meningioma surgery. Mortality was 4.2% one month and 7.3% six months after operation. 15.6% of the patients stayed more than one month in the hospital (defined as criteria of operative morbidity). Age, poor preoperative clinical condition (ASA score), intra- and postoperative bleeding and CSF disturbances were significantly associated with a subsequent decrease of quality of life. First symptoms like intracranial hypertension, seizures, aphasia and hemiparesis were correlated with an increase of postoperative Karnowsky index. Postoperative quality of life decreased in patients with optic and other cranial nerve disturbances significantly. Tumour size, location (exception: medial sphenoid wing) and histological diagnosis did not influence surgical outcome. This information may be useful in management decisions regarding asymptomatic meningiomas in elderly and high risk patients.

Is de novo hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt increased?

BACKGROUND

Portal hypertension is a major complication of liver cirrhosis. Transjugular intrahepatic portosystemic shunt is effective in treatment of portal hypertension. However, decreased parenchymal portal venous flow after transjugular intrahepatic portosystemic shunt insertion favours ischaemic liver injury which has been discussed to induce hepatocarcinogenesis causing hepatocellular cancer.

AIM

This study aimed to explore the association between transjugular intrahepatic portosystemic shunt placement and the development of hepatocellular cancer.

METHODS

A total of 1338 consecutive liver cirrhosis patients were included in this retrospective study between January 2004-December 2015. Data were analysed with regard to development of hepatocellular cancer during follow-up. Binary logistic regression and Kaplan-Meier analyses were conducted for the assessment of risk factors for hepatocellular cancer development. In a second step, to rule out confounders of group heterogeneity, case-control matching was performed based on gender, age, model of end-stage liver disease score and underlying cause of cirrhosis (non-alcoholic steatohepatitis, alcoholic liver disease and viral hepatitis).

RESULTS

Besides established risk factors such as older age, male gender and underlying viral hepatitis, statistical analysis revealed the absence of transjugular intrahepatic portosystemic shunt insertion as a risk factor for hepatocellular cancer development. Furthermore, matched-pair analysis of 432 patients showed a significant difference (p = 0.003) in the emergence of hepatocellular cancer regarding transjugular intrahepatic portosystemic shunt placement versus the non-transjugular intrahepatic portosystemic shunt cohort.

CONCLUSION

In patients with end-stage liver disease, transjugular intrahepatic portosystemic shunt insertion is significantly associated with reduced rates of hepatocellular cancer development.

Novel score for prediction of malignant bile duct obstruction based on biochemical and clinical markers

BACKGROUND

Early differentiation of malignant from benign bile duct obstruction is of utmost importance.

AIM

To identify biochemical and clinical predictors for malignancy in patients with bile duct obstruction, and establish a predictive model by combining pre-treatment patient characteristics. A web-based application was developed for easy assessment of malignant bile duct probability (www.pmal-score.org).

METHODS

One thousand hundred and thirty-five patients [median age 66 (52-75) years, 53% male] with bile duct obstruction of various aetiologies were retrospectively evaluated at our tertiary referral centre. Multivariate logistic regression analysis identified factors as independently significant for malignant bile duct obstruction. A predictive risk score was established using ROC analysis and applied to an external validation cohort of 101 patients.

RESULTS

Three hundred and ninety-four patients had malignant bile duct obstruction proven by surgery, while in 741 patients benign obstruction was observed. Multivariate analysis identified various clinical factors to be predictive for malignancy. On the basis of eight predictors, a risk score for malignancy was developed [X = 0.025 * [age] + 1.239 * [1 if weight loss, otherwise 0] - 0.235 * [1 if pain, otherwise 0] + 0.649 * [1 if diabetes, otherwise 0] + 0.896 * [1 if jaundice, otherwise 0] + 0.109 * [bilirubin] + 0.0007 * [γ-GT] + 0.0003 * [AP] - 4.374]: A significant correlation between the predicted malignancy and the actual malignancy was found by ROC (AUC: 0.862; 95% CI 0.838-0.886, P < 0.0001).

CONCLUSIONS

This predictive risk score estimates the risk of malignancy in patients with bile duct obstruction, and it seems to be very accurate. A better prediction enables both earlier diagnosis of malignant obstructive disease and improved management of patients with bile duct obstruction, which may result in reduced morbidity and mortality.

[Intestinal cryptosporidiosis in HIV infection: clinical features, course and therapy]

OBJECTIVE

To determine retrospectively the clinical features and course of HIV-associated intestinal Cryptosporidium infection and its response to paromomycin.

PATIENTS AND METHODS

Case notes of all patients treated for cryptosporidiosis over a two-year period at an HIV out-patient clinic were analysed (26 men, four women; median CD4-lymphocyte count: 20/microliter). Median follow-up time was 6(1-22) months.

RESULTS

15 patients had persistent diarrhoea, two remained asymptomatic, seven had a remission and in five the disease took a fulminant course with severe diarrhoea ending in death within 4 months. 15 of the patients died during the period of observation, eight of them of cryptosporidiosis-associated cachexia. Mean survival time was about one year. Eight patients had multiple intestinal infections at the time the diagnosis was made and seven developed them later, which correlated with the poorer survival chances. Four patients had proven and 13 probably cryptosporidiosis-associated involvement of the biliary tract, but this did not affect the survival chances. 21 of 28 patients with diarrhoea were treated with paromomycin. In 13 of them there was for a time complete or partial response to treatment, but no response in eight. Those who responded well or partially to paromomycin had a significantly better survival chance than those without response. There was no correlation between the severity of immunosuppression and the severity of the cryptosporidiosis-associated diarrhoea, the response to paromomycin and the worse survival chance in the presence of multiple intestinal infections.

CONCLUSIONS

The reasons for the different courses taken by HIV-associated cryptosporidiosis and the different therapeutic responses remain unclear. There is no known causal treatment, but 60% of patients improved temporarily on paromomycin.

Missorting of cathepsin B into the secretory compartment of CI-MPR/IGFII-deficient mice does not induce spontaneous trypsinogen activation but leads to enhanced trypsin activity during experimental pancreatitis--without affecting disease severity

The lysosomal protease cathepsin B is thought to play a crucial role in the intracellular activation cascade of digestive proteases and in the initiation of acute pancreatitis. Although cathepsin B has been shown to be physiologically present in the secretory pathway of pancreatic acinar cells it has been suggested that premature activation of zymogens requires an additional redistribution of cathepsin B into the secretory compartment. Here, we studied the role of cathepsin B targeting during caerulein-induced pancreatitis in mouse mutants lacking the cation-independent mannose 6-phosphate/insulin-like growth factor II receptor (CI-MPR) which normally mediates the trafficking of cathepsin B to lysosomes. Absence of the CI-MPR led to redistribution of cathepsin B to the zymogen granule enriched subcellular fraction and to a substantial formation of large cytoplasmic vacuoles that contained both, trypsinogen and cathepsin B. However, this did not cause premature intracellular trypsin activation in saline-treated control animals lacking the CI-MPR. During caerulein-induced pancreatitis, trypsinogen activation in the pancreas of CI-MPR-deficient animals was about 40% higher than in wild-type animals but serum amylase levels were reduced and lung damage was unchanged. These data suggest that subcellular redistribution of cathepsin B, in itself, induces neither spontaneous trypsinogen activation nor pancreatitis. Furthermore, we clearly show that a marked increase in intracellular trypsinogen activation is not necessarily associated with greater disease severity.

Over-the-Scope Clip (OTSC) application as rescue therapy for postoperative enterocutaneous fistula closure

BACKGROUND

Postoperative enterocutaneous fistulas are challenging with limited treatment options. The majority of patients with persistent fistula drainage flow require re-surgery. Recently the Over-The-Scope Clip (OTSC 11/6t, Ovesco Endoscopy, Tübingen, Germany) has become popular in Germany among surgeons and gastroenterologists for closure of perforations and bleeding vessels of the GI tract.

CASE REPORT

A 48-year-old female patient suffered from enterocutaneous fistula for four months located at the left upper corner within the enteric anastomosis of the jejunal loop leading to malnourishment. Prior attempts at fistula closure with fibrin glue application failed. An OTSC with sharp teeth (model 11/6t) was placed under continuous suction onto the fistula orifice with consecutive closure. The fistula remained closed even after a follow-up period of 12 months.

CONCLUSIONS

The authors demonstrate the technical feasibility of fistula closure by OTSC placement even in unfavorable enterocutaneous fistula positions possibly resulting in less surgical re-interventions in the future.

A new quantum chemical approach in QSAR-analysis. Parametrisation of conformational energies into molecular descriptors JMn (steric) and JSn (electronic)

Two new types of structure-related molecular descriptors, JMn and JSn, have been developed using conformational energies from quantum chemical calculations. For this purpose propipocaine (CAS 3670-68-6) was chosen as a model and 42 analogues were studied. The quantum chemical calculations were performed applying AM1 and PCILO approximation methods. Appropriate mathematical models were designed to calculate steric parameter log JM1 and electronic parameters JS1 to JS6. The values obtained for these parameters were used in multiple linear regression analysis for the evaluation of the structure-activity relationship. Furthermore, a comparison between electronic parameters JSn and sigma (Hammett) was made. The results show, that these parameters can be used successfully in predicting the biological activity of compounds in this model. Although, JS5 values are comparable to sigma-Hammett, the electronic parameter JS2 gives a better correlation in QSAR-analysis involving two parameters JS2 and log JM1.

Inhibition of Myocardin-related Transcription Factor A Ameliorates Pathological Remodeling of the Pressure-loaded Right Ventricle

Right ventricular (RV) fibrosis is associated with RV dysfunction in a variety of RV pressure-loading conditions in which RV mechanical stress is increased, but the underlying mechanisms driving RV fibrosis are incompletely understood. In pulmonary and cardiovascular diseases characterized by elevated mechanical stress and transforming growth factor-β1 signaling, myocardin-related transcription factor A (MRTF-A) is a mechanosensitive protein critical to driving myofibroblast transition and fibrosis. In this study, we investigated whether MRTF-A inhibition improves RV profibrotic remodeling and function in response to a pulmonary artery banding (PAB) model of RV pressure loading. Rats were assigned into either sham or PAB groups. MRTF-A inhibitor CCG-1423 was administered daily at 0.75 mg/kg in a subset of PAB animals. Echocardiography and pressure-volume hemodynamics were obtained at a terminal experiment 6 weeks later. RV myocardial samples were analyzed for fibrosis, cardiomyocyte hypertrophy, and profibrotic signaling. MRTF-A inhibition slightly reduced systolic dysfunction in PAB rats reflected by increased lateral tricuspid annulus peak systolic velocity, whereas diastolic function parameters were not significantly improved. RV remodeling was attenuated in PAB rats with MRTF-A inhibition, displaying reduced fibrosis. This was accompanied with a reduction in PAB-induced upregulation of Yes-associated protein (YAP) and its paralog transcriptional coactivator with PDZ-binding motif (TAZ). We also confirmed, using a second-generation MRTF-A inhibitor CCG-203971, that MRTF-A is critical in driving RV fibroblast expression of TAZ and markers of myofibroblast transition in response to transforming growth factor-β1 stress and RhoA activation. These studies identify RhoA, MRTF-A, and YAP/TAZ as interconnected regulators of profibrotic signaling in RV pressure loading and as potential targets to improve RV profibrotic remodeling.